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HomeMy WebLinkAboutInsurance Information Orientation FormsBenefits Maintenance Checklist New Employee iz Change ® Term® HR Date Accting Employee Name EE# Address Phone Number Hire Date Wage Effective Date SS#: Hourly: $ Married —Y N Date of Birth: Annual: Smokes- Y ■ N. BenTek Date Entered Lincoln Life Termination BenTek COBRA Date Lincoln Delete Date Enter Date Delete Date BenefitWkShop Date BenefitsWorkshop LTD Lincoln LTD Accept/Decline Date Date Entered Health Ins. $2500 E $5,000 One Year Anniversary Amount $ Yes ® No 11 Heath Insurance Dental Vision Life EAP Life YesEJ No 0 Supplemental Yes No Yes 1:1 No 0 Yes ■ No ■ EE Only $25.00 EE Only $0 e. EE Only EE Only EE EE Supplemental Buy -Up Plan $6.28 $0 $15,000 $00 El ® $ Premium $ EE Spouse $318.92 EE Family Spouse EE Spouse $15.08 Lj $3 76 Supplemental e BUY -up $27.76 L` ® $ Premium $ EE + Child(ren) $199.86 Children ■ EE Children) $26.22 L Supplemental Buy -up $43.64 El $ ■ Premium $ EE+Family $482.34 ■ EE +Family $41.28 61 Buy up $65.08 L, Flex Spending Account $ ■ Dependent Spending Acct. $ ■ Supplemental Insurance Yes ® No ■ Allstate Identity Theft Legal Theft $ ■ Protection Protection EE $16.90 $9 95 El Family $21.50 Dependents SS DOB Spouse Marriage Date Child Child Child Child Beneficiary for life Insurance Primary Name & Address SS# Relationship Primary Name & Address SS# Relationship Primary Name & Address SS# Relationship Contingent Name & Address SS# Relationship Contingent Name & Address SS# Relationship Contingent Name & Address SS# Relationship rJuPOU Fine c al iiroup� You're In Charge Sponsored by: City of Sebastian Retirees Coverage Life Maximum Amount Guarantee Issue AD&D Benefit Reduction Benefits will reduce: Additional Benefits See Understanding Your Benefits Page: Enrolling for Coverage Eligibility Group Term Life and AD&D Insurance SUMMARY OF BENEFITS Benefit Amount Employee One times basic annual earnings, rounded to the next higher $1,000 $15,000 $15.000 Will Equal the Life Benefit Employee Benefits terminate at employee age 99 Accelerated Death Benefit Seatbelt Benefit — Air Bag Benefit Conversion Employee All employees in an eligible class. Common Carrier Benefit (Please see other side) Understanding Your Benefits Accelerated Death Benefit Accelerated Death Benefit provides an option to be paid a portion of your life insurance benefit when diagnosed as terminally ill (as defined in the policy). The death benefit will be reduced by the amount withdrawn. To qualify, you must be covered under this policy for the amount of time defined by the policy. AD&D Accidental Death and Dismemberment (AD&D) insurance provides specified benefits for a covered accidental bodily injury that directly causes death or dismemberment (e.g., the loss of a hand, foot, or eye), subject to policy limitations. Conversion If you terminate your employment or become ineligible for this coverage, you have the option to convert all or part of the amount of coverage in force to an individual life policy on the date of termination without Evidence of Insurability. Conversion election normally must be made within 31 days of your date of termination. Guarantee Issue For timely entrants enrolled within 31 days of becoming eligible, the Guarantee Issue amount is available without providing Evidence of Insurability. Evidence of Insurability will be required for any amounts above this, for late enrollees or increases in insurance, and it will be provided at your own expense. Seatbelt Benefit — Air Bag Benefit If you die as a result of a covered auto accident while wearing a seat belt or in a vehicle - Common Carrier Benefit equipped with an airbag, additional benefits are payable up to $10,000 or 10% of the principal sum, whichever is less. If loss occurs due to an accident while riding as a passenger in a common carrier, benefits will be double the amount that would otherwise apply as outlined in the certificate. Term Life A death benefit is paid to the designated beneficiary upon the death of the insured. Coverage is provided for the time period that you are eligible and premium is paid. There is no cash value associated with this product. Additional Benefits LifeKeyssM Online will & testament preparation service, identity theft resources and beneficiary assistance support for all employees and eligible dependents covered under the Group Term Life and/or AD&D policy. TravelConnectsM Travel assistance services for employees and eligible dependents traveling more than 100 miles from home. For assistance or additional Information Contact Lincoln Financial Group at (800) 423-2765; reference ID: CIWOFSEB2 I mm.Lincoln Financial.com If there is any discrepancy between this benefit summary and the policy, the policy shall control. This summary is not intended to contain a complete description of the coverage offered. This summary does not modify the policy. This is not a binding contract Insurance products are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. Product availability and/or features may vary by state. Limitations and exclusions apply. Not for use in New York. Understanding Your Benefits Accelerated Death Benefit Accelerated Death Benefit provides an option to be paid a portion of your life insurance benefit when diagnosed as terminally ill (as defined in the policy). The death benefit will be reduced by the amount withdrawn. To qualify, you must be covered under this policy for the amount of time defined by the policy. AD&D Accidental Death and Dismemberment (AD&D) insurance provides specified benefits for a covered accidental bodily injury that directly causes death or dismemberment (e.g., the loss of a hand, foot, or eye), subject to policy limitations. Conversion If you terminate your employment or become ineligible for this coverage, you have the option to convert all or part of the amount of coverage in force to an individual life policy on the date of termination without Evidence of Insurability. Conversion election normally must be made within 31 days of your date of termination. Guarantee Issue For timely entrants enrolled within 31 days of becoming eligible, the Guarantee Issue amount is available without providing Evidence of Insurability. Evidence of Insurability will be required for any amounts above this, for late enrollees or increases in insurance, and it will be provided at your own expense. Seatbelt Benefit — Air Bag Benefit If you die as a result of a covered auto accident while wearing a seat belt or in a vehicle - Common Carrier Benefit equipped with an airbag, additional benefits are payable up to $10.000 or 10% of the principal sum, whichever is less. If loss occurs due to an accident while riding as a passenger in a common carrier, benefits will be double the amount that would otherwise apply as outlined in the certificate. Term Life A death benefit is paid to the designated beneficiary upon the death of the insured. Coverage is provided for the time period that you are eligible and premium is paid. There is no cash value associated with this product. Additional Benefits LireKeyssm Online will & testament preparation service, identity theft resources and beneficiary assistance support for all employees and eligible dependents covered under the Group Term Life and/or AD&D policy. TravelConnectsM Travel assistance services for employees and eligible dependents traveling more than 100 miles from home. For assistance or additional information Contact Lincoln Financial Group at (800) 423-2765; reference ID: CITYOFSEB2 I www.Linco]nFinancial.com If there is any discrepancy between this benefit summary and the policy, the policy shall control. This summary is not intended to contain a complete description of the coverage offered. This summary does not modify the policy. This is not a binding contract Insurance products are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. Product availability and/or features may vary by state. Limitations and exclusions apply. Not for use in New York. Lincoln Group Term Life and AD&D Insurance Financial Group• You're In Charge - SUMMARY OF BENEFITS Sponsored by: City of Sebastian Retirees Coverage Benefri`Ainount, Employee -;; . 12 Life One times basic annual earnings, rounded to the next higher $1,000 Maximum Amount $16,000 Guarantee Issue $15,000 AD&D Will Equal the Life Benefit Beniefit.Redtctiori: Emptoye�. Benefits will reduce: Benefits terminate at employee age 99 Additional Be�nefiis See Understanding Your Benefits Page: Accelerated Death Benefit Seatbelt Benefit — Air Bag Benefit - Common Carrier Benefit Conversion Enrollirig for Coverage Employee Eligibility: All employees in an eligible class. (Please see other side) Humana Dental and Vision Humana Dental Traditional Preferred 14 Non -participating dentists can bill you for charges above the amount covered by your HumanaDental plan. To ensure you do not receive additional charges, visit a participating PPO Network dentist. Members and their families benefit from negotiated discounts on covered services by choosing dentists in our network. If a member visits a participating network dentist, the member will not receive a bill for charges more than the negotiated fee for covered services. If a member sees an out -of -network dentist, coinsurance will apply to the usual and customary charge. Out -of -network dentists may bill you for charges above the amount covered by your dental plan. Waiting periods Employer -sponsored funding: 10+ enrolled employees Enrollment type Preventive Basic Major Orthodontia Initial enrollment, open enrollment No No No No and timely add -on Late applicant 1.2 No 12 months 12 months 12 months Late applicants not allowed with open enrollment option. z Waiting periods do not apply to endodontic or periodontic services unless a late applicant. 1-800-233-4013 • Humano.com Page 2 of 5 Humana Dental Traditional FLORIDA Preferred 14 Calendar -year deductible (excludes orthodontic services) Calendar -year annual maximum (excludes orthodontic services) Preventive services • Routine oral examinations (2 per year) • Bitewing x-rays (2 films under age 10, up to 4 films ages 10 and older) • Routine cleanings (2 per year) • Fluoride treatment (1 per year, through age 14) • Sealants (permanent molars, through age 14) • Space maintainers (primary teeth, through age 14) • Oral Cancer Screening (1 per year, ages 40 and older) Basic services • Emergency care for pain relief • Amalgam fillings (1 per tooth every 2 years, composite for anterior/front teeth) • Oral surgery (tooth extractions including impacted teeth) • Stainless steel crowns • Harmful habit appliances for children (1 per lifetime, through age 14) Major services Crowns (1 per tooth every 5 years) • Inlays/onlays (1 per tooth every 5 years) • Bridges (1 per tooth every 5 years) • Dentures (1 per tooth ever 5 years) • Denture relines/rebases (1 every 3 years, following 6 months of denture use) • Denture repair and adjustments (following 6 months of denture use) • Implants (1 every 5 years for implant placement, crowns, bridges, and dentures) • Periodontics (periodontal cleanings 4 per year, scaling/root planing and surgery 1 per quadrant every 3 years) • Endodontics (root canals 1 per tooth per lifetime and 1 re -treatment) If you use an IN -NETWORK dentist Individual Family $50 $150 City of Sebastian If you use an OUT -OF -NETWORK dentist Individual Family $50 $150 Deductible applies to all services excluding preventive services. $1,000 After you reach the annual maximum amount, you will receive 30 percent coinsurance on preventive, basic, and major services for the rest of the year (excludes orthodontia.) 100% no deductible, does not 100% no deductible, does not apply against annual apply against annual maximum maximum 80% after deductible 50% after deductible 80% after deductible 50% after deductible OrthOdO :C •) Child orthodontia - Covers children through age 18. Plan pays 50 percent (no deductible) of the covered orthodontia services, up to: $1,000 lifetime orthodontia maximum. 1-800-233-4013 • Humana.com Page 1 of 5 Humana Dental Traditional Preferred 14 Feel good about choosing a HumanaDental plan Make regular dental visits a priority Regular cleanings can help manage problems throughout the body such as heart disease, diabetes, and stroke.* Your HumanaDental Traditional Preferred plan focuses on prevention and early diagnosis, providing four exams and cleanings every calendar year: two regular and two periodontal. * www.perio.org Go to MyDentolIQ.com Take a health risk assessment that immediately rates your dental health knowledge. You'll receive a personalized action plan with health tips. You con print a copy of your scorecard to discuss with your dentist at your next visit. Tips to ensure a healthy mouth • Use a soft -bristled toothbrush • Choose toothpaste with fluoride • Brush for at least two minutes twice a day Floss daily Watch for signs of periodontal disease such as red, swollen, or tender gums Visit a dentist regularly for exams and cleanings Did you know that 74 percent of adult Americans believe an unattractive smile could hurt a person's chances for career success?* HumanaDental helps you feel good about your dental health so you can smile confidently. ' American Academy of Cosmetic Dentistry Questions? Simply call 1-800-233-4013 to speak with a friendly, knowledgeable Customer Care specialist, or visit Humana.com. Use your HumanaDental benefits Find a dentist With HumonaDentol's Traditional Preferred plan, you can see any dentist. Members and their families benefit from negotiated discounts on covered servcies by choosing dentists in the HumanaDental Traditional Preferred Network. To find a dentist in HumanaDental's Traditional Preferred Network, log on to Humana.com or call 1-800-233-4013. Know what your plan covers The other side of this page gives you a summary of HumanaDental benefits. Your plan certificate describes your HumanaDental benefits, including limitations and exclusions. You can find it on MyHumana, your personal page at HumanaDental.com or call 1-800-233-4013. See your dentist Your HumanaDental identification card contains all the information your dentist needs to submit your claims. Be sure to share it with the office staff when you arrive for your appointment. If you don't have your card, you can print proof of coverage at Humano.com. Learn what your plan paid After HumanaDental processes your dental claim, you will receive an explanation of benefits or claims receipt. It provides detailed information on covered dental services, amounts paid, plus any amount you may owe your dentist. You can also check the status at your claim on MyHumana at Humana.com or by calling 1-800-233-4013. Humana group dental plans are offered by Humana Insurance Company, HumanaDental Insurance Company, Humana Insurance Company of New York, Humana Health Benefit Plan of Louisiana, The Dental Concern, Inc., Humana Medical Plan of Utah, CompBenefits Company, CompBenefits Dental, Inc., Humana Employers Health Plan of Georgia, Inc. or DentiCare, Inc. (d/b/a CompBenefits) This is not a complete disclosure of plan qualifications and limitations. Your agents will provide you with specific limitations and exclusions as contained in the Regulatory and Technical Information Guide. Please review this information before applying for coverage. The amount of benefits provided depends upon the plan selected. Premiums will vary according to the selection made. Humana Humana.com Plan summary created on: 8/13/18 09:23 Policy Number: FL-70090-HC L 1/14, FL-70090-HC 5B 1114 Page 3 of 5 • If you expect to pay more than $300 for dental care, your dentist may submit a proposed dental treatment plan that Humana will use to determine if your dental benefits cover the treatment. This is known as a "predetermination of benefits" (also called "prior authorization") • The dental treatment plan may include: A list of services to be performed, including any supporting documentation A written description from the dentist of the treatment An itemized list of costs • Please note: With limited exceptions, predetermination of benefits must be granted before the service is provided. It will remain valid for up to 90 days after the review, and is not a guarantee of what we will pay toward the treatment. Humana Humana Vision 130 If you use an If you use an Vision care services IN -NETWORK provider OUT -OF -NETWORK provider (Member cost) (Reimbursement) Frequency • Examination Once every 12 months Once every 12 months • Lenses or contact lenses Once every 12 months Once every 12 months • Frame Once every 24 months Once every 24 months Diabetic Eye Care: care and testing for diabetic members • Examination $0 Up to $77 - Up to (2) services per year • Retinal Imaging $0 Up to $50 - Up to (2) services per year • Extended Ophthalmoscopy $0 Up to $15 - Up to (2) services per year • Gonioscopy $0 Up to $15 - Up to (2) services per year • Scanning Laser $0 Up to $33 - Up to (2) services per year Member costs may exceed $39 with certain providers. Members may contact their participating provider to determine what costs or discounts are available. : Standard contact lens exam fit and follow up costs and premium contact lens exam discounts up to 10% may vary by participating provider. Members may contact their participating provider to determine what costs or discounts are available. ' Discounts may be available on all frames except when prohibited by the manufacturer. ' Lens option costs may vary by provider. Members may contact their participating provider to determine if listed costs ore available. ' Plan covers contact lenses or frames, but not both. Additional plan discounts • Member may receive a 20% discount on items not covered by the plan at network Providers. Members may contact their participating provider to determine what costs or discounts are available. Discount does not apply to EyeMed Provider's professional services, or contact lenses. Plan discounts cannot be combined with any other discounts or promotional offers. Services or materials provided by any other group benefit plan providing vision care may not be covered. Certain brand name Vision Materials may not be eligible for a discount if the manufacturer imposes a no -discount practice. Frame, Lens, & Lens Option discounts apply only when purchasing a complete pair of eyeglasses. If purchased separately, members receive 20% off the retail price. • Members may also receive 15% off retail price or 5% off promotional price for LASIK or PRK from the US Laser Network, owned and operated by LCA Vision. Since LASIK or PRK vision correction is an elective procedure, performed by specialty trained providers, this discount may not always be available from a provider in your immediate location. Hu Humana Page o5 Page 2 of 5 CITY of S_ &ST.. HOME Of PELICAN ISLAND 1225 MAIN STREET • SEBASTIAN, FLORIDA = 32958 TELEPHONE: (772) 589-5330 • FAX (772) 589-5570 CONTINUATION COVERAGE RIGHTS LTI-MER COMk" , Introduction , You are receiving this notice because you will become covered under a group health plan (the Plan), upon completion of GO days of continuous full-time employment , by the City of Sebastian. This notice contains important information about your, iright,..to COBRA continuation coverage,- which is a temporary extension of coveraaepnder the Plan. This notice generally explains COBRA continuation coverage, wben.1t� _inay " become available to .you and your.fhmko a* nd what you need to.Fda to{p;<-otect the right to receive it. The right_ to COBRA _ continuation, coverage was created, by a federal law, the Consolidated Omnibus Budget- Reconciliation Act of 1985 (COBRA): COBRA continuation coverage can become available to you when you would otherwise lose you group health coverage. It can also become available to other members of. your family who are covered under the Plan when they would otherwise dose their -group health coverage. For .additional , information about your rights and obligations under the Plan and.. under -federal aw, you should. review the . Plah7s -Su 3' Plan � Desciiption or contact the Plan Administrator: 'what is COBRA Continuation Coverage? COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event .known as a ,".`qualifying event." Specific qualifying events are listed later in this notice. After a qualifying event, ` COBRAS continuation coverage must: be offered to each .person who is a "qualified beneficiary." . You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying' event. Under the Plan, qualified beneficiaries who elect COBRA. continuation coverage must pay .for COBRA continuation coverage. If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happens: • Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct "An Equal Opportunity Employer" Celebrating Our 75th Anniversary If you are the spouse of an employee; you wvi11 become a qualified beneficiary If you lose your coverage under the Plan because any of the following quahfying events happens- * Your spouse dies; Your spouse's hours of employment are reduced; Your spouse's employment ends ''for any reason other than his or her gross misconduct; ® Your~ spouse becomes entitled to Medicare benefits (under Part A, Part B. or both) or You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because any of the following qualifyingg events happens: m The parent=employee dies; The parent-employee'-s hours of employment are reduced; The parent -employee's emp dross loyment ends for any 'reason other than his or her ::-; _ - • - con . a The parent -employee -b tomes entitled -to -Medicare benefits (Part A,=Part B, or both); ®. The parents become, divorced or legally separated; or 1.' ; , . t . . !! The child -stops b eligl`ble for coverage:unde`,r' planar a 'aependen# child. When .is COBRAS.. Coveraee Available? The Plan will offer COBPLA continuation coveragd- to qualified, 'beneficiaries :only after thL Plan Administrator lass been 'notified that a qualifying event lids occurred. When the qualifying event is the end of employment or reduction of hours of employment; death of an employee, or the employee's becoming entitled , to Medicare benefits (under Part A, Part B, or both), the employer must notify the Plan Administrator of -the qualifying event. YOU Must Give Notice of Some Oualifin¢ events For the other qualifying events (divorce or leaai separation of the employee and spouse or a denendent child's losing eligibility fo covera a as a dependent child), you :roust notify the Plan Administrator within 60 days after the qualifying event occurs. You roust provide this notice, along with any necessary documentation, to the Denefats Specialist in Human Rssources. How is COBRA Coveraze Provided? Once the Plan Administrator receives notice that a qualifying event has occurred, C.10B ci continuation cove awe vVild be offered to each of the qualified beneficiarnes. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage o behalf of their spouses, and parents may elect COBRA► continuation coverage on behalf lof,.their children. , COBRA continuation coverage is a temporary continuation of coverage. When .the qu fying event is 'the death of the employee, the employee's becoII ing entitled to Medicare' benefits (under Part A, Part B, or both), your divorce of legal separation, or a de .,naent child's Iosink'6ligibilitty as ,a de` :endent child, COBRA_ continuation .coverage lasts for up to a total of 36 months. When'& quahfying event is thVe end Hof emplayiosent or reduction of the employee's hours of employment, and the employee became entitled to Ivlcdicare benefits less Ahan 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other. -than the employer lasts .until. 36 months after the date .of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare' 8 Ynoriths before the date' on �-which' his e4lo*6nfi terminates, COBRA continuation coverage for his spouse and children can�last up -to -36 months after the date of M1 dicare entitlement which h"is equal -to -28 months after -'the date of the qualifying event (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the .employee's hours of employment, COBRA continuation coverage generally lasts for only up to a*total..of 18 months._ There are -two ways in which this 18-month period of COBRA continuation coverage can be extended. ,Disability extension of l8-month period -of co,n6"U'a* Lion coverage If you or anyone in your family covered under the. Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to have started at some time before, the 60th day of COBRA continuation coverage and ,must last at least until the end of the 18 month period of continuation coverage. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA. continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to the Plan. This extension may be available .to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first quaff*a event not occurred. If You Have Ocaestions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability. .Act (HIPPA), and . other Taws affecting group health ..plans, , contact the nearest. Regional, or District. Oface of the.'U.S..I]epartment of Laboi's Employee_Benefits Secuxity _.Administration (E$SA) in ::your area . or visit the' ;EBSA website at rw-w:do1. aovlebsa. (pddesses : and phone 'number's of,.Regionaj and;si�t EBA Qfiices are[ available through EBSA's website.) KeeD Your Plan Informed ofAddress Cha.nzes In order to protect. your, farm y's rights, you should keep the Plan':; . *** ` i istrator .infor ned ofi any changes in .the addresses .of family members. You' should also keep a copy, -for your records, of any notices you send _to the Plan Adrninsraor. :Phan Contact Information Tnfor=nation regarding COBRA'S continuation coveraje can be obtained upon request from the Benefits Specialist in the Human. Resources Department or from' - the Plan Administrator, Florida Munk al Insurance Trust, �°.®, Box 530065, Orlando, Florida 32853-0065. I acknowledge receipt of the Continuation Coverage Rights under COBRA. I have read this document and understand its content. I understand that this document is not a contractual document and that none of its provisions constitute contractual terms or conditions of employment. Signed: , Date: (Employee Signature) Signed: Date: (Spouse Signature) It is necessary that you and your spouse (if applicable) sign this form and return to the Human Resources Department. BenefitsWorkshop P. O. Box 66828 Jacksonville, FL 32241 Acting on behalf of the Plan Sponsor: City of Sebastian February 7, 2018 First Name Last Name and Family Address 1 Address 2 City, State Zip INITIAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS *'CONTINUATION COVERAGE RIGHTS UNDER COBRA''*** Introduction k -4 4D 13 Rkftl You're getting this notice because you have recently gained or may soon gain coverage under a group health plan (the Plan). If you are a participant in a group health plan this notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan's Summary Plan Description or contact the Plan Sponsor. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse's plan), even if that plan generally doesn't accept late enrollees. What Is COBRA Coveraae? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a "qualifying event." Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a "qualified beneficiary." You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you're an employee, you'll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct. If you're the spouse of an employee, you'll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your spouse dies; • Your spouse's hours of employment are reduced; • Your spouse's employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: • The parent -employee dies; • The parent -employee's hours of employment are reduced; • The parent -employee's employment ends for any reason other than his or her gross misconduct; • The parent -employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a "dependent child." Page 1 of 3 When Is COBRA Coverage Available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Sponsor has been notified that a qualifying event has occurred. The employer must notify the Plan Sponsor of the following qualifying events: • The end of employment or reduction of hours of employment; • Death of the employee; • Commencement of a proceeding in bankruptcy with respect to the employer;]; or • The employee's becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child's losing eligibility for coverage as a dependent child), you must notify the Plan Sponsor within 60 days after the qualifying event occurs. You must provide this notice to your Employer's Human Resources Department. If these procedures are not followed or if the notice is not provided during the 60-day notice period, THEN ALL QUALIFIED BENEFICIARIES WILL LOSE THEIR RIGHT TO ELECT COBRA. How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse's plan) through what is called a "special enrollment period." Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www_healthcare. oov. If You Have Questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's website.) For more information about the Marketplace, visit www.HealthCare.00v. Keep Your Plan Informed of Address Chances In order to protect your family's rights, you should keep the Plan Sponsor informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Sponsor or BenefitsWorkshop. Page 2 of 3 Plan Contact Information You may obtain information about the Plan and COBRA coverage from: BenefitsWorkshop P. 0. Box 56828 Jacksonville, FL 32241 Phone: 888-537-3539 (for information only, not for notification of qualifying events) Fax: 904-880-2830 Email: COBRA@BenefitsWorkshop.com This contact information for the Plan may change from time to time. The most recent information will be included in the Plan's most recent summary plan description (if you do not have a copy, you may request one from the Plan Sponsor). Notice Procedures Warning: If your notice is late or if you do not follow these notice procedures, you and all related qualified beneficiaries will lose the right to elect COBRA (or will lose the right to an extension of COBRA coverage, as applicable). Notices Must Be Written and Submitted on Plan Forms: Any notice that you provide must be in writing and must be submitted on the Plan's required form (the Plan's required forms are described above in this notice, and you may obtain copies from BenefitsWorkshop without charge or download them at www. BenefitsWorkshor).com/cobra ). Oral notice, including notice by telephone, is not acceptable. Electronic (including e-mailed or faxed) notices are not acceptable. How, When, and Where to Send Notices: Notice of qualifying events should be sent to the Plan Sponsor. If you have been offered COBRA coverage because of a qualifying event, all communications should be with BenefitsWorkshop using one of the methods the listed in the Plan Contact Information paragraph. However, if a different address for notices to the Plan appears in the Plan's most recent summary plan description, you must mail or hand deliver your notice to that address (if you do not have a copy of the Plan's most recent summary plan description, you may request one from the Plan Sponsor). If mailed, your notice must be postmarked no later than the last day of the applicable notice period (The applicable notice periods are described in the paragraph above entitled "When is COBRA coverage available?" and elsewhere herein. Information Required for All Notices: Any notice you provide must include: (1) the name of the Plan Sponsor and the name of the Welfare Benefit Plan (2) the name and address of the employee who is (or was) covered under the Plan; (3) the name(s) and address(es) of all qualified beneficiary(ies) who lost coverage as a result of the qualifying event; (4) the qualifying event and the date it happened; and (5) the certification, signature, name, address, and telephone number of the person providing the notice. Additional Information Required for Notice of Qualifying Event: If the qualifying event is a divorce or legal separation, your notice must include a copy of the decree of divorce or legal separation. If your coverage is reduced or eliminated and later a divorce or legal separation occurs, and if you are notifying BenefitsWorkshop that your Plan coverage was reduced or eliminated in anticipation of the divorce or legal separation, your notice must include evidence satisfactory to BenefitsWorkshop that your coverage was reduced or eliminated in anticipation of the divorce or legal separation. Additional Information Required for Notice of Disability: Any notice of disability that you provide must include: (1) the name and address of the disabled qualified beneficiary; (2) the date that the qualified beneficiary became disabled; (3) the names and addresses of all qualified beneficiaries who are still receiving COBRA coverage; (4) the date that the Social Security Administration made its determination; (5) a copy of the Social Security Administration's determination; and (6) a statement whether the Social Security Administration has subsequently determined that the disabled qualified beneficiary is no longer disabled. Additional Information Required for Notice of Second Qualifying Event: Any notice of a second qualifying event that you provide must include: (1) the names and addresses of all qualified beneficiaries who are still receiving COBRA coverage; (2) the second qualifying event and the date that it happened; and (3) if the second qualifying event is a divorce or legal separation, a copy of the decree of divorce or legal separation. Who May Provide Notices: The covered employee (i.e., the employee or former employee who is or was covered under the Plan), a qualified beneficiary who lost coverage due to the qualifying event described in the notice, or a representative acting on behalf of either may provide notices. A notice provided by any of these individuals will satisfy any responsibility to provide notice on behalf of all qualified beneficiaries who lost coverage due to the qualifying event described in the notice. Page 3 of 3 Document ID Revision 10/1/2021 Effective Date 10/1/2021 Signatur �� PURPOSE ih0 �=:.C= t.4,y HOME OF PELICAN ISLAND Title Print Date Family and Medical Leave Act 10/01/2021 (FM LA) Prepared By: Cynthia Watson Date Prepared Human Resources Director 10/01/2021 Reviewed By: Date Reviewed Manny Anon, City Attorney 09/10/2021 Approved By: Date Approved Paul Carlisle, City Manager 09/02/2021 The purpose of this policy is to provide employees with a general description of their FMLA rights. In the event of any conflict between this policy and the applicable law, employees will be afforded all rights required by law. If you have any questions, concerns or disputes with this policy, please contact the Human Resources Department. The City of Sebastian complies with the Family and Medical Leave Act (FMLA) and will grant up to 12 weeks of leave during a 12-month period to eligible employees (or up to 26 weeks of military caregiver leave). ELIGIBILITY To be eligible for leave under this policy, employees must meet all of the following requirements: 1. Worked for a covered employer; 2. Have worked at least twelve (12) months for City of Sebastian; 3. Have worked at least 1,250 hours for City of Sebastian over the previous twelve (12) months from the date the leave would commence; 4. Currently work at a location where there are at least fifty (50) employees within seventy-five (75) miles. EMPLOYMENT ELIGIBILITY Employees must meet certain requirements to be eligible for FMLA leave benefits. The 12 months of employment do not have to be consecutive. Employment periods prior to a break in service of 7 years or more need not be counted, unless the break is associated with the employee's fulfillment of his/her National Guard or Reserve military obligation, or a written agreement exists indicating the employer's intention to rehire the employee after the break in service. Thus, all periods of absence from work due to or necessitated by service in the uniformed services are counted as hours worked in determining eligibility. REASONS FOR LEAVE To qualify as FMLA leave under this policy, the leave must be for one of the following reasons: 1. The birth and care of a newborn child of the employee; 0 HONIE OF PELICAN ISLAND 2. For incapacity due to pregnancy, prenatal medical care or child birth; 3. The placement with the employee of a son or daughter for adoption or foster care; 4. To care for an immediate family member (spouse, child or parent) with a serious health condition; 5. For a serious health condition that makes the employee unable to perform the essential functions of his or her job; 6. For any qualifying exigency arising out of the fact that a spouse, child or parent is a military member on covered active duty or call to covered active duty status; or 7. To care for a covered service member with a serious injury or illness. AMOUNT OF LEAVE An eligible employee can take up to 12 weeks of FMLA leave during any 12-month period. The City will measure the 12-month period as a calendar 12-month period. Each time an employee takes leave, the City will compute the amount of leave the employee has taken under this policy in the last 12 months and subtract it from the 12 weeks of available leave, and the balance remaining is the amount the employee is entitled to take at that time. An eligible employee can take up to 26 weeks for the FMLA military caregiver leave during a single 12- month period. For this military caregiver leave, the City will measure the 12-month period as a calendar year. FMLA leave already taken for other FMLA circumstances will be deducted from the total of 26 weeks available. Eligible spouses who both work for the City may only take a combined total of 12 weeks of leave for the birth of a child, adoption or placement of a child in foster care, or to care for a parent (but not a parent "in- law") with a serious health condition. Both may only take a combined total of 26 weeks of leave to care for a covered injured or ill service member (if each spouse is a parent, spouse, child or next of kin of the service member). INTERMITTENT LEAVE OR A REDUCED WORK SCHEDULE Employees may take FMLA leave in one consecutive block of time, may use the leave intermittently (take a day periodically when needed over the year) or, under certain circumstances, may use the leave to reduce the workweek or workday, resulting in a reduced hour schedule. In all cases, the leave may not exceed a total of 12 workweeks (480 hours) (or 26 workweeks to care for an injured or ill service member) in a 12-month period. The City may temporarily transfer an employee to an available alternative position with equivalent pay and benefits if the alternative position would better accommodate the intermittent or reduced schedule, in instances when leave for the employee or employee's family member is foreseeable and for planned medical treatment, including recovery from a serious health condition or to care for a child after birth or placement for adoption or foster care. FMLA leave may be taken intermittently/reduced schedule whenever medically necessary to care for a seriously ill family member, or because the employee is seriously ill and unable to work. Only the amount of leave actually taken while on intermittent/reduced schedule leave may be charged as FMLA leave. Employees may not be required to take more FMLA leave than necessary to address the circumstances that cause the need for leave. For the birth, care or placement for adoption or foster care of a child, the City and the employee must mutually agree to the schedule before the employee may take the leave intermittently or work a reduced- an ti SEeEnAN HOME OF PELICAN ISLAND hour schedule. Leave for birth, adoption or foster care of a child must be taken within one year of the birth or placement of the child. When leave is needed for planned medical treatment, the employee must make a reasonable effort to schedule treatment so as not to unduly disrupt the City's operations. EMPLOYEE NOTICE AND CERTIFICATION REQUIREMENT Employees must provide thirty (30) days advance notice of the need to take leave. All employees requesting FMLA leave must provide verbal or written notice of the need for leave to the Department Director or Human Resources Director when they are absent from work for three or more consecutive work days on sick leave. If thirty (30) day notice is not possible, the employee must provide notice as soon as practicable and generally must comply with an employer's normal call -in procedures. Employees must provide sufficient information to the employer to determine if the leave may qualify for FMLA protection and provide the anticipated liming and duration of the leave. When an employee becomes aware of a need for FMLA leave fewer than thirty (30) days in advance, the employee must provide notice of the need for the leave either the same day the need for leave is discovered or the next business day. When the need for FMLA leave is not foreseeable, the employee must comply with the City's usual and customary notice and procedural requirements for requesting leave, absent unusual circumstances. Employees must also inform the employer if the requested leave is for a reason for which FMLA leave was previously taken or certified. Employees may also be required to provide a certification and periodic recertification to support the need for leave. Within five (5) business days after the employee has provided this notice, the Human Resources Director will complete and provide the employee with a Notice of Eligibility and Rights (Exhibit 1); request an Employee/Family Member Medical Certification (Exhibits 2 and 3), supporting the need for leave due to a serious health condition affecting the employee or his/her spouse, child, or parent; and other supporting documentation, as necessary. If the employee fails to provide timely notice, the FMLA leave request may be delayed or denied and may be subject to whatever discipline the employer's rules provide. DESIGNATION OF FMLA LEAVE Within five (5) business days after the employee has submitted the required certification or other documentation, the Human Resources Director will complete and provide the employee with a written response to the employee's request for FMLA leave using the FMLA Designation Notice (Exhibit 4). EMPLOYEE STATUS AND BENEFITS DURING LEAVE City of Sebastian will continue an employee's health benefits during the leave period at the same level and under the same conditions as if the employee was continuously at work. While on paid leave, the employer will continue to make payroll deductions to collect the employee's share of insurance premiums. While on unpaid leave, the employee must continue to make its share of insurance premium payments, either in person or by mail. The payment must be received in the Administrative Services Department by the 20th day of each month. tm.r SE,BASTIAN HOME OF PELICAN ISLAND If the payment is more than thirty (30) days late, the employee's health care coverage may be terminated during the FMLA leave for failure by the employee to maintain his/her contributions. The City will provide fifteen (15) days notification prior to the employee's loss of coverage. If the employee chooses not to return to work for reasons other than a continued serious health condition of the employee or the employee's family member or a circumstance beyond the employee's control, the City will require the employee to reimburse the City the amount it paid for the employee's health insurance premium during the leave period. If the employee contributes to a life insurance or disability plan, the City will continue making payroll deductions while the employee is on paid leave. While the employee is on unpaid leave, the employee may request continuation of such benefits and pay his or her portion of the premiums, or the City may elect to maintain such benefits during the leave and pay the employee's share of the premium payments. If the employee does not continue these payments, the City will discontinue coverage during the leave. If the City maintains coverage, the City may recover the costs incurred for paying the employee's share of any premiums, whether or not the employee returns to work. EMPLOYEE STATUS AFTER LEAVE — FITNESS FOR DUTY CERTIFICATION FMLA regulations allow employers to enforce uniformly applied policies or practices that require all similarly situated employees who take leave to provide certification that they are able to resume and return to work. This requirement will be included in the City's response to the FMLA request. An employee who takes leave under this policy may be asked to provide a fitness for duty clearance from a health care provider for the following reasons: First, an employee may require that the certification specifically address the employee's ability to perform the essential functions of the employee's job. Second, where reasonable job safety concerns exist, an employer may require a fitness -for -duty certification before an employee may return to work when the employee takes intermittent leave. Generally, an employee who takes FMLA leave will be able to return to the same position or a position with equivalent status, pay, benefits and other employment terms. The position will be the same or one that is virtually identical in terms of pay, benefits and working conditions. The City may choose to exempt certain key employees from this requirement and not return them to the same or similar position when doing so will cause substantial and grievous economic injury to business operations. Key employees will be given written notice at the time FMLA leave is requested of his or her status as a key employee. USE OF PAID AND UNPAID LEAVE An employee who is taking FMLA leave because of the employee's own serious health condition or the serious health condition of a family member must use all paid sick leave, personal or vacation leave prior to being eligible for unpaid leave. Sick leave will run concurrently with FMLA leave if the reason for the FMLA leave is covered by the established sick leave policy. If their accrued paid leave benefits are exhausted, employees may take unpaid FMLA leave until the conclusion of the approved leave. Employees on Workers' Compensation leave (to the extent that they qualify), that runs concurrently with their FMLA leave, are not required to use their accrued paid leave benefits.. An employee who is taking leave for the adoption or foster care of a child must use all paid vacation or personal prior to being eligible for unpaid leave. an ,v SE13AST" ar HOME OF PELICAN ISLAND An employee who is using military FMLA leave for a qualifying exigency must use all paid sick, vacation and personal leave prior to being eligible for unpaid leave. An employee using FMLA military caregiver leave must also use all paid sick, personal leave or vacation leave (as long as the reason for the absence is covered by the City's sick leave policy) prior to being eligible for unpaid leave. The City of Sebastian will determine if an employee's use of paid leave counts as FMLA leave, based upon information received from the employee. INTENT TO RETURN TO WORK FROM FMLA LEAVE On a basis that does not discriminate against employees on FMLA leave, the City requires an employee on FMLA leave to report periodically on the employee's status and intent to return to work. Pi'GL=P, I\:10141by-Va 1_1111"1�Ia MW-11 When a holiday falls during a week in which an employee is taking the full week of FMLA leave, the entire week is counted as FMLA leave. However, when a holiday falls during a week when an employee is taking less than the full week of FMLA leave, the holiday is not counted as FMLA leave, unless the employee was scheduled and expected to work on the holiday and used FMLA leave for that day. EMPLOYEE'S RESPONSIBILITY WHILE ON LEAVE 1. An employee granted a leave of absence in excess of twelve (12) weeks shall contact his/her department and inform his/her Director, or designee, on a monthly basis, (unless other reporting arrangements have been approved in advance), of his/her current status and intent to return to work. 2. An employee on a leave of absence shall keep his/her department advised of any change in his/her current address and telephone number, if applicable. 3. An employee who is granted a leave of absence must notify and make arrangements with the Human Resources Department prior to the effective date of the leave and advise if they wish to continue or discontinue any form of group insurance coverage. 4. Extensions requested by the employee beyond the twelve (12) weeks must be requested in writing and require the approval of the Department Head, the Human Resources Director and City Manager. RETURN FROM LEAVE OF ABSENCE/JOB RESTORATION 1. An employee who returns to work within the twelve (12) week entitlement will be returned to the same position. If circumstances have changed so as to make that impossible or unreasonable as determined by the City Manager or Human Resources Director, the employee shall be placed in an equivalent position with equivalent benefits, pay and other terms and conditions of employment. 2. An employee who has utilized the twelve (12) week entitlement and is granted an extension shall be permitted to return to work to his/her prior position or classification providing a vacancy exists and he/she is able to perform the essential functions of the job with or without accommodation. If a vacancy does not exist, the City shall make a reasonable effort to transfer him/her within thirty (30) calendar days to a position for which he/she is qualified. If no position is available, he/she shall be terminated and shall be eligible for reinstatement to his/her classification for a period of one (1) year. F. HOME OF PELICAN ISLAND 3. An employee wishing to return to work from a medical leave of absence is required to provide the Department Head with a one (1) week notice prior to his/her requested date of return, to include a fitness for duty certification from the health care provider that he/she is available to resume all of the essential functions of his/her position, including regular attendance and is fit for duty. The City has a right to request a second or third examination, at the City's expense, prior to approving the employee's return to work. The City shall not be responsible for the employee's time and incidental expenses. Restoration will be denied by the employer if the employee fails to provide the required fitness for duty certification. 4. An employee may voluntarily return to work by accepting a light duty assignment. By doing so, however, the employee could exhaust restoration rights under FMLA prior to FMLA time being exhausted. 5. Also, an employee under a workers' compensation leave that is running concurrently with his/her FMLA leave, could forfeit workers' compensation benefits if he/she refuses a light duty assignment offered by the employer in conjunction with the workers' compensation claim. 6. An employee's use of FMLA leave cannot result in the loss of any employee benefit that the employee earned or was entitled to before using FMLA leave, nor be counted against the employee under a "no fault" attendance policy. 7. Under specified and limited circumstances where restoration to employment will cause substantial and grievous economic injury to its operations, an employer may refuse to reinstate certain highly paid "key" employees after using FMLA leave during which health coverage was maintained. A "key" employee is a salaried "eligible" employee who is among the highest ten percent of employees compensated, within 75 miles of the work site. S. Benefits and protection under the FMLA leave end if the employee fails to return to work within the 2-week entitlement, therefore, the employee is not entitled to restoration under FMLA. UNLAWFUL ACTS BY EMPLOYERS FMLA makes it unlawful for any employer to: 1. Interfere with, restrain, or deny the exercise of any right provided under FMLA. 2. Discharge or discriminate against any person for opposing any practice made unlawful by, FMLA or for involvement in any proceeding under or relating to FMLA. ENFORCEMENT The Wage and Hour Division investigates complaints. If violations cannot be satisfactorily resolved, the U.S. Department of Labor is authorized to investigate, resolve complaints of violations and bring action in court to compel compliance. An eligible employee may also bring civil action against an employer for violations. FMLA does not affect any Federal or State law prohibiting discrimination, or supersede any State or Local law or collective bargaining agreement which provides greater family or medical leave rights. DEFINITIONS Serious health condition means an illness, injury, impairment, or physical or mental condition that involves inpatient care or continuing treatment by a health care provider. This can include conditions with short-term, chronic, long-term or permanent periods of incapacity. Spouse means a husband or wife as defined or recognized in the state where the individual was married and includes individuals in a common law or same -sex marriage. Spouse also includes a husband or wife OnO SE T _N HOME OF PELICAN ISLAND in a marriage that was validly entered into outside of the United States, if the marriage could have been entered into in at least one state. Child means a biological, adopted or foster child, a stepchild, a legal ward, or a child of a person standing in loco parentis, who is either under age 18, or age 18 or older and "incapable of self -care because of a mental or physical disability' at the time that FMLA leave is to commence. Parent means a biological, adoptive, step or foster father or mother, or any other individual who stood in loco parentis to the employee when the employee was a child. This term does not include parents "in law." Qualifying exigency includes short -notice deployment, military events and activities, child care and school activities, financial and legal arrangements, counseling, rest and recuperation, post -deployment activities, and additional activities that arise out of active duty, provided that the employer and employee agree, including agreement on timing and duration of the leave. Covered active duty for members of a regular component of the Armed Forces, means duty during deployment of the member with the Armed Forces to a foreign country. For a member of the Reserve components of the Armed Forces, means duty during the deployment of the member with the Armed Forces to a foreign country under a federal call or order to active duty in support of a contingency operation, in accordance with 29 CR 825.102. The next of kin of a covered service member is the nearest blood relative, other than the covered service member's spouse, parent or child in the following order of priority: blood relatives who have been granted legal custody of the service member by court decree or statutory provisions, brothers and sisters, grandparents, aunts and uncles, and first cousins, unless the covered service member has specifically designated in writing another blood relative as his or her nearest blood relative for purposes of military caregiver leave under the FMLA. Covered service member is a current member of the Armed Forces, including a member of the National Guard or Reserves, who is receiving medical treatment, recuperation or therapy, or is in outpatient status or on the temporary disability retired list for a serious injury or illness. Serious injury or illness is one that is incurred by a service member in the line of duty on active duty that may cause the service member to be medically unfit to perform the duties of his or her office, grade, rank or rating. A serious injury or illness also includes injuries or illnesses that existed before the service member's active duty and that were aggravated by service in the line of duty on active duty. For additional Information Contact the nearest office of Wage and Hour Division U.S. Department of Labor Employment Standards Administration Wage and Hour Division 200 Constitution Ave., NW Washington, DC 20210 1866-4-USA-DOL CalC* 1; LA HOME OF PELICAN ISLAND CITY OF SEBASTIAN RECEIPT OF FAMILY MEDICAL LEAVE POLICY This will acknowledge my receipt of the City of Sebastian's Family Medical Leave Policy. I have read this policy and understand its contents. I will contact my supervisor or the Human Resources Department for clarification if at any time in the future I do not understand any portion of this policy. 1 agree to be responsible for any revisions and/or updates to the Policy and for deletion of any obsolete material therein, which I receive. I recognize that this policy is not a contractual document, and that none of its provisions constitute contractual terms or conditions of employment. I also recognize that the City Manager may alter, supplement, delete or amend any portion of this policy at any time at his/her sole discretion. My signature attests to the fact that I have read this Policy, that I am familiar with its contents, and that I will act accordingly. Employee's Signature Name (Printed) Date HEALTH PLAN NOTICES OF PRIVACY PRACTICES Notice for Medical Information: Pages 3 - 6. Notice for Financial Information: Page 7. Medical Information Privacy Notice Effective January 1, 2017 We' are required by law to protect the privacy of your health information. We are also required to send you this notice, which explains how we may use information about you and when we can give out or "disclose" that information to others. You also have rights regarding your health information that are described in this notice. We are required by law to abide by the terms of this notice. The terms "information" or 'health information" in this notice include any information we maintain that reasonably can be used to identify you and that relates to your physical or mental health condition, the provision of health care to you, or the payment for such health care. We will comply with the requirements of applicable privacy laws related to notifying you in the event of a breach of your health information. We have the right to change our privacy practices and the terms of this notice. If we make a material change to our privacy Practices, we will provide to you, in our next annual distribution, either a revised notice or information about the material change and how to obtain a revised notice. We will provide you with this information either by direct mail or electronically, in accordance with applicable law. In all cases, if we maintain a website for your particular health plan, we will post the revised notice on your health plan website, such as www.mvuhc.com or www.oxfordheatth,com. We reserve the right to make any revised or changed notice effective for information we already have and for information that we receive in the future. United Health Group collects and maintains oral, written and electronic information to administer our business and to provide Products, services and information of importance to our enrollees. We maintain physical, electronic and procedural security safeguards in the handling and maintenance of our enrollees' information, in accordance with applicable state and federal standards, to protect against risks such as loss, destruction or misuse. How We Use or Disclose Information We must use and disclose your health information to provide that information: • To you or someone who has the legal right to act for you (your personal representative) in order to administer your rights as described in this notice: and • To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected. We have the right to use and disclose health information for your treatment, to pay for your health care and to operate our business. For example, we may use or disclose your health information: For Payment of premiums due us, to determine your coverage, and to process claims for health care services you receive, including for subrogation or coordination of other benefits you may have. For example, we may tell a doctor whether you are eligible for coverage and what percentage of the bill may be covered. • For Treatment. We may use or disclose health information to aid in your treatment or the coordination of your care. For example, we may disclose information to your physicians or hospitals to help them provide medical care to you. For Health Care Operations. We may use or disclose health information as necessary to operate and manage our business activities related to providing and managing your health care coverage. For example, we might talk to your physician to suggest a disease management or wellness program that could help improve your health or we may analyze data to determine how we can improve our services. • To Provide You Information on Health Related Programs or Products such as alternative medical treatments and programs or about health -related products and services, subject to limits Imposed by law. For Plan Sponsors. If your coverage is through an employer sponsored group health plan, we may share summary health information and enrollment and disenrollment information with the plan sponsor. In addition, we may share other health information with the plan sponsor for plan administration purposes if the plan sponsor agrees to special restrictions on its use and disclosure of the information in accordance with federal law. For Underwriting Purposes. We may use or disclose your health information for underwriting purposes; however, we will not use or disclose your genetic information for such purposes. • For Reminders. We may use or disclose health information to send you reminders about your benefits or care, such as appointment reminders with providers who provide medical care to you. We may use or disclose your health information for the following purposes under limited circumstances: • As Required by Law. We may disclose information when required to do so by law. To Persons Involved With Your Care. We may use or disclose your health information to a person involved in your care or who helps pay for your care, such as a family member, when you are incapacitated or in an emergency, or when you agree or fail to object when given the opportunity. If you are unavailable or unable to object, we will use our best judgment to decide if the disclosure is in your best interests. Special rules apply regarding when we may disclose health information to family members and others involved in a deceased individual's care. We may disclose health information to any persons involved, prior to the death, in the care or payment for care of a deceased individual, unless we are aware that doing so would be inconsistent with a preference previously expressed by the deceased. • For Public Health Activities such as reporting or preventing disease outbreaks to a public health authority. • For Reporting Victims of Abuse, Neglect or Domestic Violence to government authorities that are authorized by law to receive such information, including a social service or protective service agency. • For Health Oversight Activities to a health oversight agency for activities authorized by law, such as licensure, governmental audits and fraud and abuse investigations. • For Judicial or Administrative Proceedings such as in response to a court order, search warrant or subpoena. • For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime. • To Avoid a Serious Threat to Health or Safety to you, another person, or the public, by, for example, disclosing information to public health agencies or law enforcement authorities, or in the event of an emergency or natural disaster. • For Specialized Government Functions such as military and veteran activities, national security and intelligence activities, and the protective services for the President and others. • For Workers' Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job -related injuries or illness. • For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets federal privacy law requirements. • To Provide information Regarding Decedents. We may disclose information to a coroner or medical examiner to identify a deceased person, determine a cause of death, or as authorized by law. We may also disclose information to funeral directors as necessary to carry out their duties. • For Organ Procurement Purposes. We may use or disclose information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate donation and transplantation. • To Correctional institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution. • To Business Associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. Our business associates are required, under contract with us and pursuant to federal law, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract and as permitted by federal law. • Additional Restrictions on Use and Disclosure. Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. "Highly confidential information" may include confidential information under Federal laws governing alcohol and drug abuse information and genetic information as well as state taws that often protect the following types of information: 1. HIV/AIDS; 2. Mental health; 3. Genetic tests; 4. Alcohol and drug abuse; 5. Sexually transmitted diseases and reproductive health information; and 6. Child or adult abuse or neglect, including sexual assault. 4 If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law. Attached to this notice is a "Federal and State Amendments" document. Except for uses and disclosures described and limited as set forth in this notice, we will use and disclose your health information only with a written authorization from you. This includes, except for limited circumstances allowed by federal privacy law, not using or disclosing psychotherapy notes about you, selling your health information to others, or using or disclosing your health information for certain promotional communications that are prohibited marketing communications under federal law, without your written authorization. Once you give us authorization to release your health information, we cannot guarantee that the recipient to whom the information is provided will not disclose the information. You may take back or "revoke" your written authorization at any time in writing, except if we have already acted based on your authorization. To find out where to mail your written authorization and how to revoke an authorization, call the phone number listed on your health plan ID card. What Are Your Rights The following are your rights with respect to your health information: You have the right to ask to restrict uses or disclosures of your information for treatment, payment, or health care operations. You also have the right to ask to restrict disclosures to family members or to others who are involved in your health care or payment for your health care. We may also have policies on dependent access that authorize your dependents to request certain restrictions. Please note that while we will try to honor your request and will permit requests consistent with our policies, we are not required to agree to any restriction. • You have the right to ask to receive confidential communications of information in a different manner or at a different place (for example, by sending information to a P.O. Box instead of your home address). We will accommodate reasonable requests where a disclosure of all or part of your health information otherwise could endanger you. In certain circumstances, we will accept your verbal request to receive confidential communications; however, we may also require you confirm your request in writing. In addition, any requests to modify or cancel a previous confidential communication request must be made in writing. Mail your request to the address listed below. You have the right to see and obtain a copy of certain health information we maintain about you such as claims and case or medical management records. If we maintain your health information electronically, you will have the right to request that we send a copy of your health information in an electronic format to you. You can also request that we provide a copy of your information to a third party that you identify. In some cases, you may receive a summary of this health information. You must make a written request to inspect and copy your health information or have your information sent to a third party. Mail your request to the address listed below. In certain limited circumstances, we may deny your request to inspect and copy your health information. If we deny your request, you may have the right to have the denial reviewed. We may charge a reasonable fee for any copies. You have the right to ask to amend certain health information we maintain about you such as claims and case or medical management records, if you believe the health information about you is wrong or incomplete. Your request must be in writing and provide the reasons for the requested amendment. Mail your request to the address listed below. If we deny your request, you may have a statement of your disagreement added to your health information. You have the right to receive an accounting of certain disclosures of your information made by us during the six years prior to your request. This accounting will not include disclosures of information made: (i) for treatment, payment, and health care operations purposes; (ii) to you or pursuant to your authorization; and (iii) to correctional institutions or law enforcement officials; and (iv) other disclosures for which federal law does not require us to provide an accounting. You have the right to a paper copy of this notice. You may ask for a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. If we maintain a website, we will post a copy of the revised notice on our website. You may also obtain a copy of this notice on your plan website, such as www.mv_uhc.com or www.oxfordhealth.com. 5 Exercising Your Rights • Contacting your Health Plan. If you have any questions about this notice or want information about exercising your rights, please call the toll -free member phone number on your health plan ID card or you may contact a UnitedHeafth Group Customer Call Center Representative at 1-866-633-2446 (TTY 711). • Submitting a Written Request. You can mail your written requests to exercise any of your rights, including modifying or cancelling a confidential communication, requesting copies of your records, or requesting amendments to your record, to us at the following address: United Healthcare Customer Service - Privacy Unit PO Box 740815 Atlanta, GA 30374-0815 • Filing a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us at the address listed above. You may also notify the Secretary of the U.S. Department of Health and Human Services of your complaint. We will not take any action against you for filing a complaint. 2This Medical Information Notice of Privacy Practices applies to the following health plans that are affiliated with UnitedHealth Group: ACN Group of California, Inc.. All Savers Insurance Company; All Savers Life Insurance Company of California; AmeriChoice of Connecticut, Inc.; Inc.: AmeriChoice of New Jersey, Inc.; Arizona Physicians IPA, Inc.; Care Improvement Plus of Texas Insurance Company: Care Improvement Plus South Central Insurance Company; Care Improvement Plus Wisconsin Insurance Company: Dental Benefit Providers of California, Inc.; Dental Benefit Providers of Illinois, Inc.; Golden Rule Insurance Company; Health Plan of Nevada, Inc.; MAMSI Life and Health insurance Company; MD - Individual Practice Association, Inc.; Medica Health Plans of Florida, Inc.; Medica Healthcare Plans, Inc.: National Pacific Dental, Inc.: Neighborhood Health Partnership, Inc.: Nevada Pacific Dental, Optimum Choice, Inc.; Opium Insurance Company of Ohio, Inc.; Oxford Health Insurance, Inc.; Oxford Health Plans (CT), Inc.: Oxford Health Plans (NJ). Inc., Oxford Health Plans (NY), Inc.; PacifiCare Life and Health Insurance Company; PacifiCare Life Assurance Company; PacifiCare of Arizona, Inc.; PacifiCare of Colorado, Inc.; PacifiCare of Nevada, Inc.; Physicians Health Choice of Texas, LLC: Preferred Care Partners. Inc.. Sierra Health and Life Insurance Company, Inc.; UHC of California; U.S. Behavioral Health Plan, California; Unimerica Insurance Company; Unimerica Life Insurance Company of New Yale Unison Health Plan of Delaware, Inc.; Unison Health Plan of the Capital Area, inc.; UnitedHealthcare Benefits of Texas, Inc.: UnitedHeafthcare Community Plan of Georgia, Inc.: UnitedHealtheare Community Plan of Ohio, inc.; UnitedHealthcare Community Plan, Inc.. UnitedHealthcare Community Plan of Texas, LLC.; UnhadHealthcare Insurance Company, UndedHealthcare Insurance company of Illinois; UnitedHealtheare Insurance Company of New York; UnitedHealthcaue Insurance Company of the River Valley; UnitedHealthcare Life Insurance Company; UnitedHeafthcare of Alabama, Inc.: UnitedHeafthcare of Arizona, Inc.; UnitedHealtheare of Arkansas, Inc.; UnitedHeafthcare of Colorado, Inc.; UnitedHealthcare of Forda, Inc.. UnitedHealthcare of Georgia, Inc.; UnitedHealthcare of Illinois, Ina; UnitedHealthcare of Kentucky, Ltd.; UndedHealthcare of Louisiana, Inc.; UnitedHealthcare of the Mid -Atlantic, Inc.; UnitedHeaftheare of the Midlands, Inc,; UnitedHealthcare of the Midwest, Inc.; United Healthcare of Mississippi, Inc.; UnitedHealthcare of New England, Inc.; UnitedHeafthcare of New Mexico. Inc.; Unitedi-leallhcare of New York, Inc.; UnitedHealthcare of North Carolina, Inc.; UnitedHealthcare of Ohio, Inc.; UnitedHealthcare of Oklahoma, Inc.: UnitedHealthcare of Oregon, Inc.; UnitedHealthcare of Pennsylvania, Inc.; UndedHealtheare of Texas, Inc.; Uniledhlealthcare of Utah, Ina; UnitedHeafthcare of Washington, Inc.; UnitedHealthcare of Wisconsin. Inc.: UnitedHealtheare Plan of the River Valley, Inc. Financial Information Privacy Notice Effective January 1, 2017 We' are committed to maintaining the confidentiality of your personal financial information. For the purposes of this notice, "personal financial Information" means information about an enrollee or an applicant for health care coverage that identifies the individual, is not generally publicly available, and is collected from the individual or is obtained in connection with providing health care coverage to the individual. Information We Collect Depending upon the product or service you have with us, we may collect personal financial information about you from the following sources: • Information we receive from you on applications or other forms, such as name, address, age, medical Information and Social Security number: • Information about your transactions with'us, our affiliates or others, such as premium payment and claims history; and • Information from a consumer reporting agency. Disclosure of Information We do not disclose personal financial information about our enrollees or former enrollees to any third party, except as required or permitted by law. For example, in the course of our general business practices, we may, as permitted by law, disclose any of the personal financial information that we collect about you, without your authorization, to the following types of institutions: To our corporate affiliates, which include financial service providers, such as other insurers, and non -financial companies, such as data processors; To nonaffiliated companies for our everyday business purposes, such as to process your transactions, maintain your accounts), or respond to court orders and legal investigations: and • To nonaffiliated companies that perform services for us, including sending promotional communications on our behalf. Confidentiality and Security We maintain physical, electronic and procedural safeguards, In accordance with applicable state and federal standards, to protect your personal financial information against risks such as loss, destruction or misuse. These measures include computer safeguards, secured files and buildings, and restrictions on who may access your personal financial information. Questions About This Notice If you have any questions about this notice, please call the toll -free member phone number on your health plan ID card or contact the UnitedHealth Group Customer Call Center at 1.866-633-2446 (TTY 711). 'For purposes of this Rn inclal Informatics Privacy Notice.'we' or `us- refers tot" entitles listed in footnote 2, beginning on page six of the Health Plan Notices of Privacy Practices. plus the following UniitedHeaMhcare affiliates- Alers Women's and Chilthen's Health, LLC; AmeriChoice Heats Ser icess, Inc.: Com extions HCI, LLC; Dental Benefit Prwioers, Inc; getheaMinsurance.cwn Agency Inc.: Golden Outlook, Inc; Health.Allies, Inc.; UfePrint Fast, Inc; Life Print Health, Inc.: MAMSI Insurance Resources. LLC; Managed Physical Network Inc: OneNet PPO. LLC: OpiumHaatth Care Solutions, Inc.: OOhoNel, LLC: OMONet of the Mid-Allanlic, Inc: OnhoNet West, LLD.: OrewNet of the South. Inc.: Oxford Benera Management. Inc_ Orford Heath Plans LLC; Specters. Inc: UMR. Inc: Unison Administrative Sen dcas. LLC: United Behavioral Health; United Behavioral Health of New yolk LPA. Inc_ United Healthcare Services. Inc.: UntedHealth Advisors. LLC. UnifadHeallheeane Serrice, LL(:: UnitedHeakhcare Services Company of the RNef Valley. Inc-: UnitwHealmOne Agency Inc This nnanaal Information Privacy Notice only applies where required by law. Specifically, It dues not apply to (1) health care ,nsuranre products crated in Nevada by Health Plan of Nevada. Inc and Sierra Health and Life Insurance Company, Inc.; m (2) other UnitedHeaah Group health plans instates that prwide exceptions fm HIPAA wvedd entities or health Insurance products. UnitedHealth Group Health Plan Notices of Privacy Practices: Federal and State Amendments Revised: January 1, 2017 The first part of this Notice, which provides our privacy practices for Medical Information (pages 3-6), describes how we may use and disclose your health information under federal privacy rules. There are other laws that may limit our rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules. The purpose of the charts below is to: 1. show the categories of health information that are subject to these more restrictive laws; and 2. give you a general summary of when we Gan use and disclose your health information without your consent. If your written consent is required under the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law. Summary of Federal Laws Alcohol & Orug016use Information We are allowed to use and disclose alcohol and drug abuse information that is protected by federal law only (1) in certain limited circumstances, and/or disclose only (2) to specific recipients. Genetic Information We are not allowed to use genetic information for underwriting purposes-. 1 Summary of State Laws `uenertilleat l.,.rd/MtaLUll We we allowed to disclose general health information only (1) under certain limited circumstances, and/or (2) to AR, CA. DE, NE, NY, PR, RI, VT. W� specific recipients. WI HMOs must give enrollees an opportunity to approve or refuse disclosures. subject to certain exceptions. KY You may be able to restrict certain electronic disclosures of health information. INC, NV We are not allowed to use health Information for certain purposes. I CA, IA We will not use and/or disclose information regarding certain public assistance programs except for certain purposes. i KY. MO. NJ. SD We must comply with additional restrictions prior o using or disclosing your health information for certain purposes. KS Prescriptions We ere allowed to disclose prescription -related information only (1) under certain limited circumstances. and/or (2) to I ID. NH, NV speoilic recipients Communicable Diseases We are allowed to disclose communicable disease information only (1) under certain limited circumstances, and/or (2) to IAZ, IN. KS. MI, NV. OK specific recipients, fIA 541Abai, rr'aBf11iK(9'b uissases ame Abproouctive Neki th We are allowed to disclose sexually transmitted disease and/or reproductive health information only (1) under certain limited circumstances and/or (2) to specific recipients. A,conol eta Drug Abuse We are allowedto use and disclose alcohol and drug abuse information (1) under certain limited circumstances. and/or disclose only (2) to specific recipients. Disclosures of alcohol and tlmg abuse information may be restricted by the Individual who is the subject of the information. waneee.nnod lLon We are not allowed to disclose genetic Information wiout your written consent. We are allowed to disclose genetic infornalion only (1) under certain limited circumstances and/or (2) to specific recipients. I Restrictions apply to (1) the use, and/or (2) the retention of genetic information. HIV /-. - ` - re are allowed to disclose HN/AIDS+ Iated information only `I) under certain Ilmiter'cimumstances and/or (2) to specific recipients. Certain restrictions apply to oral disclosures of HIV/AIDS-related information. We will collect certain HIV/AIDS-related information only with your written consent Mental Health We are allaweri to disclose menCaf hea t�h information only (1) under certain liimited c ri cumstancm and/or (2) to specific recipients. Disclosures may be restricted by the individual who is the subject of the information. Certain restrictions apply to oral discloaures of mental health information. Certain restrictions apply to the use of mental health information. �\Child o, W#;C Alasil t%e are allowedrto use and discLe child and/or aduli96use InformaCion only (1(under certain �miYed circumstances.antl/or disclose only (2) to specific recipients. CA, FL, IN, KS. MI, MT, NJ. NV PR. VIA. WY MN, AR, CT, GA. KY, IL, IN, IA, LA, NO. NH, ON, WA, WI WA CA, CO, KS. KY, LA. NY RI, TN. W V AK, AZ, Ft. GA, It., IA, MD, ME, MA, MO, NJ. NV, NH, NM, OR, RI, TX, UT, VT FL, GA, IA, LA, MD, NM, OH, UT, VA, VT AZ, AR. Ck CT. de. FL, GA, IA. KS, KY, ME, MI, MO, MT, NY, NO, NH, NM. NV, OR, PA. PR, RI, TX VT, WV, WA, WI, WY CT, FL I OR I CA, CT al.' IA, fL AN, KY MA. MI, NO. NM. PR. TN, WA- WI WA I CT ME IA, UF.vy.&,w�i RI, TN, TX tiT, W I MT-1107266,0 10/16 s 2016 United Heollhl areServices, Inc. is 16,?260 Language Assistance Services We' provide free language services to help communicate with us. We offer interpreters, letters in other languages, and letters in large print. To get help, please call 1-866-633-2446, or the toll -free member phone number listed on your health plan ID card (TTY 711). We are available Monday through Friday. 8 a.m. to 8 p.m. E.T. ATENCION: Si habla espanol (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposici6n. Llame al 1-866-633-2446. UM" : 0jRR rP� (Chinese) , 'jA A t �j�� 0 : 1-866-633-24460 XIN LUU ' T: Neu quy A n6i tieng Viet (Vietnamese), quy A se dtlrgc cung cap dick vu trq giup ve ngon ng r mien phi. Vui long goi 1-866-633-2446. a o: O GM (Korean) M A F o o f A I o °i Oi 7CI " JH d l T z 01 a o f z' T e d LI Q. 1-866-633-2446 UL a -if-- i Qf of d� AI 4. PAUNAWA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng serbisyo ng tulong sa wika. Mangyaring tumawag sa 1-866-633-2446. BHHMAHHE: 6ecrmatHwe ycnyrH nepesoAa AocTynxr,1 Anx moAeft, qeH po,4HOH- Asbrx AB]IAeTCA pyccrcoM (Russian). IIosBOHHTe no HOMepy 1-866-633-2446. .1-866-633-2446 -? JL-o:Nl PUS JI A �li,o %aul Sl a„y�iZI L 1 u1.o.3S jl9 (Arabic) +,}*31 , ",s 1:�1 ATANSYON: Si w pale Kreyol ayisyen (Haitian Creole), ou kapab benefisye s6vis ki gratis you ede w nan lang pa w. Tanpri rele nan 1-866-633-2446. ATTENTION: Si vous parlez frangais (French), des services d'aide linguistique vous sont proposes gratuitement. Veuillez appeler le 1-866-633-2446. UWAGA: Je2eli mowisz po polsku (Polish), udostgpnili§my darmowe uslugi tlumacza. Prosimy zadzwonic pod numer 1-866-633-2446. ATENQAO: Se voce fala portugues (Portuguese), contate o servigo de assistencia de idiomas gratuito. Ligue para 1-866-633-2446. ATTENZIONE: in caso la lingua, parlata sia 11taliano (Italian), sono disponibili servizi di assistenza linguistica gratuiti. Si prega di chiamare it numero 1-866-633-2446. ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche Hilfsdiensdeistungen zur Verf igung. Rufen Sie 1-866-633-2446 an. :'It S*M (Japanese)�j�4L�fA , ; 0Apax-!"—t�xi�-ft1fLNt::tDf 3 To 1-866-633-2446 IZ8` ;;2i< --t-Lio .. cfA L4,1,"l j.3 uLS.�I, JJL cs4� .31.141 CJ 1,C.WI (Farsi) Lq"jt9 Lam►; Cj1,_) _AI :A.� .jA uAIZ 1-866-633-2446 WW CT t: zrfk XT " (Hindi) 3 TPt 9 itr i1 I %126 ' c4V M *I F 1 q cl I ;� cl T0 Pr. q1 Fw � 4 c16tT 91 WW qT � � 1-866-633-2446 CEEB TOOK Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau 1-866-633-2446. �ttmtifnt�ari: t�e�s,;��m,rtutt�t(Khmer)inmcgec:n,�ntimmenita�a �rnB�mvn, �irg,n�2 iv�rae 1-866-633-2446, PAKDAAR: Nu saritaem ti Ilocano (Iloeano), ti serbisyo pars ti baddang 6 lengguahe nga awanan bayadna, ket sidadaan pars kenyam. Maidawat nga awagan iti 1-866-633-2446. Dff BAA'�iKONINIZIN: Dine (Navajo) bizaad bee yanihi'go, saad bee aka'anida'awo'igii, t'aa juk'ek bee na'ah6ot'i'. TAU shoodi kohji' 1-866-633-2446 hodiilnih. OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageemda luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac 1-866-633-2446. Notice of Non -Discrimination We' do not treat members differently because of sex, age, race, color, disability or national origin. If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a complaint to: Civil Rights Coordinator United HealthCare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130 UHC—Civil—Rights@uhc.com You must send the complaint within 60 days of the incident. We will send you a decision within 30 days. If you disagree with the decision, you have 15 days to appeal. If you need help with your complaint, please call 1-866.633-2446 or the toll -free member phone number listed on your health plan ID card (TTY 711). We are available Monday through Friday, 8 a.m. to 8 p.m. E.T. You can also file a complaint with the U.S. Dept. of Health and Human services. Online: https.//ocrportal.hhs.gov/ocr/portal/lobbyisf Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Phone: Toll -free 1-800-368-1019, 800-537-7697 (TDD) Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 'For purposes of the Language Assistance Services and this Non-Discrirnination Notice ("Notice"). 'We" refers to the entities listed in Footnote 2 of the Notice of Privacy Practices and Footnote 3 of the financial Information Privacy Notice. Please note that not all entities listed are covered by this Notice. 2 Notice of Privacy Practices Form New Health Insurance Marketplace Coverage Options and Your Health Coverage Form On this day of , I received the Notice of Privacy Practices Policy and the New Health Insurance Market place Coverage Options and Your Health Coverage Form. Signature Date Human Resources — Signature Date 0 15399700v.2 New Health Insurance Marketplace Coverage Form Approved Options and Your Health Coverage OMB No. 31 -201 49 P 9 (expires 13t-2017) PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment -based health coverage offered by your employer. What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one -stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014. Can I Save Money on my Health Insurance Premiums In the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income. Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost -sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household Income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit.' Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer -offered coverage. Also, this employer contribution -as well as your employee contribution to employer -offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after- tax basis. How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information. Including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area. ' An employer -sponsored health plan meets the "minimum value standard- if Ire plan's shaje of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs. PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application. 3. Employer name 4. Employer Identification Number (EIN) City of Sebastian 596000427 5. Employer address 6. Employer phone number 1225 Main Street 772-388-8222 7. City 8. State 9. ZIP code Sebastian FL 1 32958 10. Who can we contact about employee health coverage at this job? Cynthia Watson, Human Resources Manager 11. Phone number (if different from above) 12. Email address 772-388-8222 cwatson@cityofsebastian.org Here is some basic information about health coverage offered by this employer: .As your employer, we offer a health plan to: 0 All employees. Eligible employees are: Eligible employees working a minimum of 30 hours per week. Coverage will be effective the 1st of the month following 60 days of employment. ❑ Some employees. Eligible employees are: With respect to dependents 0 We do offer coverage. Eligible dependents are: A legal spouse and/or dependent child(ren) of the participant or the spouse. A natural child, step child, legally adopted child, foster child, a newborn (up to age 18 mo. of a covered dependent (Florida), and a child for whom legal guardianship has been awarded to the participant or the participants spouseldomestic partner ❑ We do not offer coverage. 0 It checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages. *+ Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid —year, or if you have other income losses, you may still qualify for a premium discount. If you decide to shop for coverage in the Marketplace, HealthCare gov will guide you through the process. Here's the employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums. The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is _optional for employers, but will help ensure employees understand their coverage choices. 13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months? m Yes (Continue) 13a. If the employee Is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage?On the lst following 60 days (mm/dd/Yyyy) (Continue) ❑ No (STOP and return this form to employee) 14. Does the employer offer a health plan that meets the minimum value standard*? ✓Q Yes (Go to question 15) ❑ No (STOP and return form to employee) 15. For the lowest -cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $ 12.50 ($25.00) b. How often? Q Weekly 0 Every 2 weeks Twice a month Ej Monthly Quarterly Yearly If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don't know, STOP and return form to employee. 16. What change will the employer make for the new plan year? ❑ Employer won't offer health coverage ❑ Employer will start offering health coverage to employees or change the premium for the lowest -cost plan available only to the employee that meets the minimum value standard.* (Premium should reRect the discount for wellness programs. See question 15.) a. How much would the employee have to pay in premiums for this plan? b. How often? Q Weekly Every 2 weeks Twice a month Lj Monthly ❑ Quarterly Yearly An employer -sponsored health plan meets the "minimum value standard" it the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Iriternal Revenue Code of 1986) 01P OF SE�i`�AN HOME OF PELICAN ISLAND City of Sebastian Benefit Waiver Form Please complete the information below in order to waive/decline any of the benefits offered through the City. In order to elect benefits through the City, you will be required to log into BenTek to make these elections. Employee Name: Department: Medical Coverage: I elect to: I ❑ Elect Coverage Reason for Declining/Waiving I ❑ Other Coverage Dental Coverage: I elect to: I ❑ Elect Coverage Reason for Declining/Waiving ❑ Other Coverage Vision Coverage: I elect to: ❑ Elect Coverage Reason for Declining/Waiving ❑ Other Coverage Effective Date: to ❑ Decline/Waive Coverage ❑ Other: (please explain) ❑ Decline/Waive Coverage ❑ Other: (please explain) ❑ Decline/Waive Coverage ❑ Other: (please explain) I, the undersigned, hereby voluntarily enter into and agree to the following conditions in order to be permitted to waive my participation and that of any eligible dependent in the medical, dental, and/or vision insurance plans available to City of Sebastian employees for 2015-2016: • 1 understand and agree my election to waive the medical, dental, and/or vision insurance for myself and eligible dependents under the City of Sebastian's plans is strictly voluntary on my part. • 1 understand and agree that by electing to waive participation in the City of Sebastian's medical, dental, and/or vision insurance, I will be eligible to re -enroll in the City of Sebastian's medical, dental, and/or vision insurance only if I experience a qualifying event during the plan year, or at the next open enrollment period. Employee Signature: Date: Health Coverage Opt -Out Credit - Attestation Regarding Other Coverage I, (insert name), acknowledge that I have been offered the opportunity to enroll myself and my eligible dependents in health coverage by (insert employer name) ("Employer") for the period commencing (insert date) and ending (insert date) (the "Plan Year"). Employer intends this coverage to be minimum value and affordable, as required by the Affordable Care Act. I further understand that employees who decline the Employer's coverage and truthfully complete this attestation may qualify for an "opt - out" payment, as described in the employer's plan, enrollment materials or, where applicable the collective bargaining agreement between the employer and a collective bargaining unit representing its employees. represent and attest that the following is true and accurate: 1. I am declining the opportunity to enroll in Employer's minimum value group health coverage. 2. 1 have enrolled in or will enroll in qualifying minimum value, minimum essential coverage (other than an individual insurance policy) during the Plan Year. What is qualifying minimum value, minimum essential coverage? Qualifying coverage could include, among other types of coverage, Medicare, Medicaid, TRICARE, student health insurance, or a spouse's group health plan providing minimum value. If you are uncertain of whether your spouse's group health plan provides minimum value, you may request from your spouse's employer a copy of the plan's "Summary of Benefits and Coverage," which includes a statement regarding whether the plan provides minimum value. Qualifying coverage does not include an individual health insurance policy sold through an insurance carrier, regardless of whether that policy is sold through the Health Insurance Marketplace. If you are uncertain whether your coverage qualifies, please contact [insert employer contact information]. 3. My "tax family" has enrolled in or will enroll in qualifying minimum value, minimum essential coverage (other than an individual insurance policy) during the Plan Year. What is my "tax family"? Your tax family includes any person you reasonably intend to claim a personal exemption for on your tax return during the tax year(s) that begins or ends during the employer's plan year. Your tax family might include your spouse, your dependent children and, in certain instances, your qualifying relatives. For more information, see httos://www.irs.aov/publications/Dl7/ch03.html. If you are uncertain who is in your tax family, please consult with your tax advisor. I understand that a misrepresentation with respect to my eligibility for an opt -out payment is considered material, intentional, and is grounds for retroactive cancellation of my health coverage. I further understand that the Plan reserves the right to recoup any opt -out payment I receive based on a false or fraudulent representation. This is merely a summary of the Employer's plan. Where a conflict exists between this summary and the plan, the terms of the plan control. The Employer reserves the right to amend or terminate the plan or the opt -out payment at any time. Signed: Date Employee's Signature Authorized: Date [EMPLOYER]. {oK�`y FSA Enrollment Form Fi �'1 SIN For more Information, please visit our website or contact Customer Service. www.beneftsworkshop.com/sebastian • (888) 537.3539 • info@beneftsworkshop.wm Name Social Security Number Mailing Address City, State, ZIP Phone Please choose one. Election during Open Enrollment Effective Date October 1, 20--- Please Indicate your selection(s) below. Health Care FSA Annual Amount $ Number of Paydays Contribution each Payday $ Is this a new address? ❑ YES ❑ No ❑ cell ❑ home ❑ work Email ❑ ❑ Election during Amendment to a Plan Year an existing election Effective Date Effective Date The maximum annual amount is $5,000 per plan year Order additional cards (optional). Dependent Care FSA Annual Amount $ Number of Paydays Contribution each Payday $ The maximum annual amount is $5,000 per plan year, or $2,500 if married & filing separately. A BenefitsWorkshop Debit Card will be ordered in the employee's name only. A card can be ordered for your spouse/dependents for a $5.00 handling fee, which will be deducted from your account balance. By providing the requested information, you are authorizing BenefitsWorkshop to deduct this fee from your account. Individual cards are not required to access the account. Name SS# ❑ spouse ❑ child Name SS# ❑ spouse ❑ child By signing this form, I authorize my employer to redirect (reduce) my taxable pay by the indicated amounts. I understand and agree that: (1) 1 have read the plan materials available to me and I understand the operation and rules of the plan. (2) 1 cannot change or cancel my election for the remainder of the plan year unless I have a qualifying event. (3) 1 cannot transfer money between the reimbursement accounts. (4) Unspent funds will be forfeited after the grace period ends. (5) The elections I have made are in accordance with the plan documents and the provisions of Internal Revenue Service Code Section 125, and will be taken out in equal installments throughout the year. (6) 1 will only use the Debit Card to pay for eligible medical expenses for myself or my covered dependents. (7) 1 will not use the debit card for any medical expense that has already been reimbursed, and I will not seek reimbursement under any other health plan for expenses paid for with the debit card. (8) 1 will acquire and retain sufficient documentation for any expense paid with the debit card. Participant Signature Date F&I-N44a, Elm 00 Employee Enrollment Application An Independent Licensee of the Blue Cross and Blue Shield Association Section A: Current Information Group Name: Group #: Effective Date of Coverage: Date of Hire: Location #: Employee #: Work Status: ❑ Actively at Work ❑ Cobra ❑ Retired Retirement Date: Section B: Employee Information Social Security#: Last Name: First Name: Street Address: Job Title: Apt. #: City: Division #: Package #: Paid:[] Hourly ❑ Salary! ❑ Open Enrollment M.I.: Birth Date: Sex: ❑M❑F State: Zip: County: Phone: Marital Status: Legally ElSingle 0Mended ElDiwrced Q Widowed ❑ Separated Physician Name / ID # HMO only: I Existing Patient: Language of Preference: optional - for data collection purposes only Yes ❑ No ❑ English C Spanish ❑ Othar ❑ Prefer not to answer Ethnicity optional ❑ Asian/Pacific Islander ❑ Black/African American ❑ Caribbean Islander ❑ Hispanic ❑ Native American ❑ White Check al, that apply Section C: Health Coverage Level and Plan Information Employee Health Coverage: ❑ Employee ❑ 'Employee & Spouse ❑ 'Employee & One Dependent ❑ 'Employee & Child(ren) ❑ Family `When available ❑ BlueOptions Plan # ❑ BlueChoice (PPO) Plan # ❑ BlueSelect Plan # ❑ Other Plan # ❑ BlueCare (HMO) Plan # ❑ I am Refusing all Health Coverage at this time. I understand that if I decide to apply later coverage may not be available until the next open or special enrollment period. Signature: Date: Section D: Vision Coverage Level and Plan Information Employee Vision Coverage: ❑ Employee ❑ 'Employee & Spouse ❑ 'Employee & One Dependent ❑ *Employee & Child(ren) ❑ Family Vision Plan Choice: ❑ I am Refusing all Vision Coverage at this time. I understand that if I decide to apply later coverage may not be available until the next open or special enrollment period. Signature: Date: Section E: Dependent Information Attaci Last Name: Social (if different than employee) Security First Name, M.I. Number: s needed. with cj , Relation to You Plan a Type � a v t Physician Birth Date: " a Name/ID n a LL y HMO only N u u O `o U vm m 9i c c'ci 55 y L ❑ iJ iJ ❑ ❑ ❑ r .re Dependent Ethnicity A) AsiantPadfic Islander z B) Black/African American 15 C) Caribbean Islander i H) Hispanic m = c n 3 a N) Native American on =' - X O d > to W) White W Y y ❑❑ A B C H N W ❑❑❑ A B C H N W ❑❑❑ A B C H N W ❑❑❑ A B C H N W List the name of each dependent listed above that is married or has dependent child(ren) or lives outside of Florida. ' If you indicated "0" in "Relation to You" above for any dependents, please explain here: 22095 0914R SR Section F: Other Health Insurance Information claims processing and Prior Coverage Information In addition to this policy, do you or your dependents have any other insurance coverage (including Florida Blue plans) that will be in effect after this coverage begins? ❑ Yes ❑ No Florida Blue Contract # Medicare # Pharmacy/Medicare D # Complete the following only N this is the first time you or your dependents: (1) are enrolling for health insurance with this employer, (2) currently have health coverage; and/or (3) have any health coverage in the past 12 months that this coverage replaces OR you can attach a Certificate of Creditable Coverage. Prior Heath Carrier Name: Contract #: Effective Date: Prior Employee Hire Date: Cancel Date: List names of all family members that were covered, including yourself I understand that any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Signature: Date: Section G: Acceptance of Coverage Plan Coverage Terns I hereby apply for the coverage/membership that is selected on this form. My employer has selected health and/or vision coverage through Florida Blue and/or HMO coverage through Florida Blue HMO. I authorize my employer to deduct from my earnings my premium contribution, if any. I understand all of the following: 1. If my coverage/membership is to be issued and continued, I must meet all the group contract's requirements; 2. If my dependents' coveragetmembership, if any, is to be issued and continued, my dependents must meet all the group contract's requirements; 3. If I must pay part or all of the premium, coveragetmembership shall not become effective until Florida Blue and/or Florida Blue HMO accepts this application and assigns an effective date. I understand that membership granted to persons herein shall be subject to all provisions and limitations of the group contract. I am aware that a change in coverage of dependents may affect the amount deducted from any wages (if any) for coverage/ membership, and I hereby authorize such a change. If I am enrolling in a high -deductible health plan designated for use with a Health Savings Account (HSA) under Internal Revenue Service Code section 223, 1 recognize and authorize Florida Blue to exchange certain limited information obtained from this application with its preferred financial partner(s) for the purposes of initial enrollment in, and administration of, HSAs. I understand that if I am enrolling in an HSA qualified High Deductible Health Plan and I elect to receive Prior Carrier Credit under Florida law, my plan may no longer qualify as an HSA compatible plan. General Terns I AGREE that in the event of any controversy or dispute between Florida Blue and/or Florida Blue HMO, I and my dependents must exhaust the appeal and/or grievance processes in the benefit/member handbook issued to me. I understand that my employer is not an agent of Florida Blue and/or Florida Blue HMO. I also understand that my employer is responsible for notifying all employees of: 1. Effective dates; 2. All termination dates; 3. Any conversion, COBRA or ERISA rights or responsibilities; and 4. All other matters pertaining to coverage/membership under the group contract. When an overpayment is made, I authorize Florida Blue and/or Florida Blue HMO to recover the excess from any person or entity that received it. I acknowledge that Florida Blue and/or Florida Blue HMO coveragetmembership is contingent upon the complete, accurate disclosure of the information requested on this form. I acknowledge that, if I apply for Florida Blue and/or Florida Blue HMO coverage/membership later, coverage/membership may not be available until the next annual open enrollment or special enrollment period. I acknowledge that any applicable credit toward a health care Pre-existing Condition Exclusion Period is contingent upon the complete and accurate disclosure of information. I represent that the statements on this application are true and complete to the best of my knowledge and belief. I understand and agree that misrepresentations, omissions, concealment of facts, or incorrect statements may result in denial of benefits and/or termination of coverage/membership. I agree to be bound by the group contract's terms and conditions. Signature: Date: Health and vision insurance is offered by Blue Cross and Blue Shield of Florida, Inc., D/B/A Florida Blue. HMO coverage is offered by Health Options, Inc., D/B/A Florida Blue HMO, an HMO affiliate of Florida Blue. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. 22095 0914R SR Large Group 51+ Employee and Individual Application and Enrollment Form FLORIDA The offering company(ies) listed below, severally or collectively, as the content may require, are referred to in the Large Group Employee and Individual Application and Enrollment Farm as "Humana". Dental and Vision plans insured or administered by O Humana Insurance Company. Print clearly and completely fill in each applicable circle. Employer / Group name Employer/Group city State I I I I I I I I I I l I I l I I I I I I I I I I I I I I i I I I I m Qualifying Event Instructions O New business enrollment O New hire/Newly eligible O Dependent birth or adoption O Loss of coverage O Open Enrollment event O Rehire/Reinstatement O Marital status change O Other Employee / Individual information Last name First name H11III11111111111111111 Social Security Number Date of birth (MM/DDNYYY) ❑❑-m-I I I I I=/m/I I I I Street address I I I I I I I I I I I I I I I I I I i I I I I I Apt / Suite / PO box number Office use only Qualifying event date (MMIDD/YYYY) mlm/� I I I I Benefit effective date f(MM/DD/YYYY) m —LJ/0/ MI IIIIIIIIII�I ❑ Area code Phonenumber (C❑) �-I I I I I I I I I I I I I I I Gender O Female O Male Language of choice O English O Spanish City State Zip code County Parish I l l l l l i I I❑ I I I J) I I I I ❑❑ I I I I I,_,J I I I I I I I I I I E-mail address IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Are you actively at work? O Yes O No If not, reason: Date of full-time hire (MM/DD/YYYY) O Retiree O COBRA Other: ml m/ ❑_❑ J Do you have a disability that affects your ability to communicate or read? O No O Yes Are you disabled or unable to perform normal work activities? O No O Yes If yes, indicate reason: Annualsolary 5 I I I II I Hours worked per week Occupation Dependent information Enter information for each covered dependent, including spouse. 1 Dependent last name First name MI Gender 1 1 1 1 1 1 1 I 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1❑ O Female O Male Social Security Number Date of birth (MM/DD/YYYY) Relationship ❑ - m - ❑ I J ❑ / ❑ / ❑ I ❑ O Spouse O Child O Other: Dependent status (if applicable): O Full-time student O Disabled If disabled, indicate reason: 2 Dependent last name First name MI Gender I I I I I I I I I I I I I I I) I I I I I I I I I I I I I❑ O Female O Male Social Security Number Date ofbirth (MM/DD/YYYY) Relationship ❑ - m - I I I I J ❑ / ❑ / ❑ I 1 O Spouse O Child O Other Dependent status (if applicable): O Full-time student O Disabled If disabled, indicate reason: FL-72001 11/2015 1 Reorder# FL-52000-LG 8/2017 3 Dependent last name First name MI IIIIIIIIIIIIIIIIIIIIIIIIIIIII❑ Social Security Number I Date of birth (MM/DD/YYYY) Relationship = - ❑ - ❑ / ❑ / I I I I 1 o Spouse O Child O Other: Dependent status (if applicable): 0 Full-time student 0 Disabled If disabled, indicate reason: 4 Dependent last name First name MI IIIIIIIIIIIIIIIIIIIIIIIIIIIII❑ Social Security Number Date of birth (MM/DD/YYYY) Relationship -❑ -i i i i J =/ m/ I 11 1 1 0 Spouse O Child O Other: Dependent status (if applicable): O Full-time student O Disabled If disabled, indicate reason: Use the following alternate address for these dependents: 01 0 2 0 3 0 4 Gender O Female O Male Gender O Female O Male Street address Apt / Suite / PO box number 1 1 1 1 1 1 I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I City State Zip code County ItI1IIillillII11111 ❑ IIIIIIIIIII11111 Dental Coverage type: O Employee / Individual only O Employee / Individual & spouse O Employee / Individual & child(ren) O Family O Other Office use only Group # Benefit # __ -- 1=_F_ L! _ _ Class/Div # Plan name I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I Within the post 12 months, haveyou or any covered family individual had any dental or orthodontia coverage, such as a spouse's dental coverage? O Yes O No Ifyes, list all: (This section must be completed for Humana to process any dental claims) Orthodontia Starting date End date, if applicable Current dental carrier name: coverage? (MM/DD/YYYY) (MM/DD/YYYY) I I I I I I I I I I I 1OYes 0No ❑/❑/I I I I I❑/❑/I I I I I Coverage Type (check all that apply) O Employee / Individual O Spouse O Child(ren) Orthodontia Starting dote End date, if applicable Prior dental carrier name: coverage? (MM/DD/YYYY) (MM/DD/YYYY) I I I I I I I I I I I 1OYes 0No ❑/❑/I I I I I=/❑/ I I I I Coverage type check all that apply) O Employee / Individual only O Employee / Individual and spouse OEmployee / Individual and child(ren) 0Family Employeeprimary care dentist name Dentist ID# Current patient? DHMO I I I I I I I I I I I I I I I I I I I I I 1 1 1 1 O Yes O No DePendentprimarycare dentist name Dentist ID# Current patient? 1 DHMO I P I l l ry l l l l I I I I I I I O Yes O No 2 DHMO I I I I I I I I I I I I I I O Yes O No 3 DHMO I I I I I I I I I I l l l I I O Yes o No Coverage type: O Employee / Individual only Office use only O Employee / Individual & spouse Group # Benefit # Class/Div # 0Employee / Individual &child(ren) 1 -� I J_ L O Family O Other Plan name I I I I I I I I I I I I I III I I I I I I I I I I I FL-7200111/2015 2 Reorder # FL-52000-LG 8/2017 Waiver (refusal of coverage) I hereby waive coverage for (check all that apply): I decline to apply for group coverage Dental for: O Myself O My spouse O My dependent child(ren) because of: Vision for: 0Myself 0Myspouse 0 My dependent child(ren) O Spousal coverage O Medicare supplement O Individual coverage O Coverage under another carrier's plan provided by my employer / group O Other: True and complete acknowledgment I understand, agree, and represent: • I have read the Large Group Employee and Individual Application and Enrollment Form or it has been read to me and answers provided are true and complete to the best of my knowledge and belief. • Neither my employer / group nor the agent can waive any question, determine coverage or insurability, alter any contract or waive any of Humana's other rights and requirements. • If the Large Group Employee and Individual Application and Enrollment Form for coverage is accepted, coverage will be effective on the date specified by Humana on the policy or certificate. • If I have a new dependent as a result of a qualifying event, I may in the future be able to enroll myself or my dependents provided I request enrollment within 31 days afterthe qualifying event. • If I or my dependents become eligible for premium or rate subsidies under Medicaid or the Children's Health Insurance Program (CHIP), I may in the future be able to enroll myself or my dependents provided I request enrollment within 60 days after the qualifying event. • In the event that I should decide to apply for coverage hereafter, that subsequent Large Group Employee and Individual Application and Enrollment Form shall be subject to the applicable terms and conditions of the master group contract(s), policy provisions or certificate provisions which may require additional limitations and waiting periods. • If I am declining coverage for myself or my dependents (including my spouse) because of coverage under Medicaid or CHIP, I may in the future be able to enroll myself or my dependents provided that I request enrollment within 60 days after my coverage under these programs ends. • If am declining coverage for myself or my dependents (including my spouse) because of other coverage, I may in the future be able to enroll myself or my dependents provided that I request enrollment within 31 days after my other coverage ends. If any deductions are required for this coverage, I authorize those deductions from my earnings. If I am applying for coverage for my dependents (including my spouse) I attest by my signature below, I have gathered the necessary health information from my dependents in order to fully and truthfully complete the Large Group Employee and Individual Application and Enrollment Form. An act of fraud or an intentional misrepresentation of a material fact may void or terminate an individual's or group's coverage as specified under the terms of the Policy or Certificate. Providing incomplete, inaccurate, or untimely information may reduce an individual's or group's coverage or may increase post premium. Rates or premium quoted and the effective date requested are not guaranteed. The final rate or premium and effective date will be determined upon underwriting review and approval of the Large Group Employee and Individual Application and Enrollment Form by Humana. Any person who willingly and knowingly submits the Large Group Employee and Individual Application and Enrollment Form containing a false, incomplete or deceptive statement may be guilty of insurance fraud. If you decide not to sign this agreement, we will decline to enroll you in on insurance product or to give you insurance benefits Authorization My dependents and I understand and agree: • The information obtained by use of this outhorization may be used by Humana to make claims determinations, determine eligibility for coverage, eligibility for benefits under an existing policy and plan administration. • Any information obtained will not be released by Humana to any person or organization except to reinsuring companies, the Medical Information Bureau, Inc, or other persons or organizations performing health care operations or business or legal services in connection with the Large Group Employee and Individual Application and Enrollment Form, claim or as may be otherwise lawfully required, or as I (we) may further authorize. The Large Group Employee and Individual Application and Enrollment Form, together with any supplemental forms, will make up part of any contract and be the basis for any policy or certificate. Signature - Please sign below if enrolling orwaiving any group coverage Any person who knowingly and with intent to injure, defraud or deceive any insurer files o statement of claim or on application containing any false, incomplete or misleading information is guilty of a felony of the third degree. Employee / Individual or legal representative signature Name and relationship of legal representative (if a covered dependent) FL-720011112015 Date m/ m/ Reorder # FL-52000-LG 8/2017 Discrimination is Against the Law Humana Inc. and its subsidiaries comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. Humana Inc. and its subsidiaries do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Humana Inc. and its subsidiaries provide: • Free auxiliary aids and services, such as qualified sign language interpreters, video remote interpretation, and written information in other formats to people with disabilities when such auxiliary aids and services are necessary to ensure an equal opportunity to participate. • Free language services to people whose primary language is not English when those services are necessary to provide meaningful access, such as translated documents or oral interpretation. If you need these services, call 1-877-320-1235, or if you use a TTY, call 711. If you believe that Humana Inc. and its subsidiaries have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Discrimination Grievances P.O. Box 14618 Lexington, KY 40512-4618 If you need help filing a grievance, call 1-877-320-1235 or if you use a TTY, call 711. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html Multi -Language Interpreter Services English: ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call 1-877-320-1235 (TTY: 711). Espanol (Spanish): ATENCION: si habla espanol, tiene a su disposicion servicios gratuitos de asistencia linguistica. Llame al 1-877-320-1235 (TTY: 711). E133Z (Chinese): 512 : 0M!0 *f r-P3ZnRo 1-877-320-1235 (TTY: 711) ° Tieng Viet (Vietnamese): CHID Y: Neu ban not Tieng Viet, co cac dich vu ho trq ngon ngu' mien phi danh cho ban. Goi so" 1-877-320-1235 (TTY: 711). � M �M(Korean): T°Iz4o�, ;R2P- oloofN T °!a�lcF, 1-877-320-1235 (TTY: 711)'LI-i o `i s 116 -"T-�`�1 AI Q . Tagalog (Tagalog - Filipino): PAUNAWA: Kung nagsasalita ka ng Taqaloq, maaari kang gumamit ng raga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-320-1235 (TTY: 711). PyccKwvl (Russian): BH14MAHME: Ecim Bbl rOBOPHTe Ha pyCCKOM 93blKe, TO BaM AocTynHb1 6ecnnaTHble ycnyrvl nepeBOAa. 3BOHv1Te 1-877-320-1235 (TeneTaOn: 711). Kreyol Ayisyen (French Creole): ATANSYON: Si w pale Kreyol Ayisyen, gen sevis ed you lang ki disponib gratis you ou. Rele 1-877-320-1235 (TTY: 711). Fran�ais (French): ATTENTION : Si vous parlez fran�ais, des services d'aide linguistique vous sont proposes gratuitement. Appelez le 1-877-320-1235 (ATS : 711). Polski (Polish): UWAGA: jezeli mowisz po polsku, mozesz skorzystac z bezplatnej pomocy jgzykowej. Zadzwo6 pod numer 1-877-320-1235 (TTY: 711). Portugues (Portuguese): ATEN�AO: Se fala portugues, encontram-se disponiveis servi4os linguisticos, gratis. Ligue para 1-877-320-1235 (TTY: 711). Italiano (Italian): ATTENZIONE: In caso la lingua parlata sia I'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare it numero 1-877-320-1235 (TTY: 711). Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zurVerfugung. Rufnummer: 1-877-320-1235 (TTY: 711). a.jmJl (Arabic): 1-877-320-1235 �.�'I .v� �1 }91 g:3 a�gs�Ul o.scL�ll uLo.s.� vl9 ,asJJl �531 �..u5131:al�gn-.J.O .(711 :f,<Jt, ?.. l e +-U to j) a (Japanese):1-877-320-1235 (TTY :711) ,.,wjls (Farsi): 1-877-320-1235 V .,s„iV uo jasaly4 l SIB► _)L vlsj as,}SI ;a�.91 63 (TTY: 711) Dine Bizaad (Navajo): Dii baa ako ninizin: Dii saad bee yanilti'go Dine Bizaad, saad bee aka'anida'awo'd�4; t'aa jiik'eh, ei na hol4, kojl' hodiilnih 1-877-320-1235 (TTY: 711). Lincoln. Financial Group► The Lincoln National Life Insurance Company P.O. Box 2616, Omaha, NE 68103-2616 Phone: (800) 423-2765 Fax: (877) 573-6177 ENROLLMENT FORM FOR GROUP INSURANCE Please Use Ink or Type I GROUP ID: CITYOFSEB2 I GROUP POLICY #: Billing Division or Location: A: Employee Information(Complete-for ATl;-Enrollment—s) --- — —� - — Employer Name/Company Name (Please Print) County Employer ZIP State City of Sebastian Employee Last Name First Name Middle Initial Social Security Number Date of Birth Spouse Last Name First Name Middle Initial Social Security Number Date of Birth Street Address City .State Zip Gender: ❑ Male ❑ Female Marital Status: ❑ Married ❑ Single Home Phone Work Phone Completed By Employer Average Hours, Worked Per Week: Occupation: Earnings: []Hourly ❑Monthly CWeekly ❑Yearly Date of Full -Time Employment: Rehire Date: B. Product Selection (Complete for ALL Enrollments) Basic Coverage NOTE: Please mark the box or boxes for each coverage you are applying for. All coverage amounts are subject to the limitations and exclusions as stated in the policy. Class Effective Type of Coverage Amount of Coverage Total Date Premium Basic Group Life/AD&D ®Yes ❑No* $ Long Term Disability ®Yes ❑No* $ Employer Paid Employer Paid Voluntary Coverage NOTE: Please mark the box or boxes for each coverage you are applying for. All coverage amounts are subject to the limitations and exclusions as stated in the policy. - TYPE OF COVERAGE AMOUNT OF COVERAGE TOTAL PREMIUM Voluntary Employee Life and AD&D Insurance ❑Yes ❑No* $ $ Voluntary Spouse Life and AD&D Insurance ❑Yes ❑No* $ $ Voluntary Dependent Child Benefit ❑Yes ❑No* I $ *By selecting No, application for coverage at a later date may require further medical information and/or a physical exam, which will be at my own expense. --Actual deductions may vary slightly from above illustrations due to rounding— C. Beneficiary Information (Complete ONLY for Life/AD&D or Accident with AD&D) Primary Beneficiary's Last Name First MI Relationship of Beneficiary Social Security Number Street Address City State Zip Contingent Beneficiary's Last Name First MI Relationship of Beneficiary Social Security Number Street Address City State Zip Note: A Contingent Beneficiary will receive benefits only if the Primary Beneficiary does not survive you. If you wish to designate more than one Primary or Contingent Beneficiary, please attach a separate sheet of paper. GLAD 4 01/12 FL E. Request for Coverages This coverage has been offered to me and after careful consideration of the benefits, I have decided to: ❑ REQUEST COVERAGE for which I am or may become eligible under the group policies issued by The Lincoln National Life Insurance Company. I hereby enroll for group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct premiums from my salary. 0 NOT ENROLL myself in the Program. I understand that if I enroll for coverage at a later date, and if a physical exams an Lion or - further medical information is required; it will be at my own expense. ❑ NOT ENROLL my dependents in the Program. I understand that if I enroll for coverage for my dependents at a later date, and if a physical examination or further medical information is required, it will be at my own expense. NOTE: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER, FILES A STATEMENT OF CLAIM, OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION, IS GUILTY OF A FELONY OF THE THIRD DEGREE. The insurance requested on this enrollment form will not be effective until approved by the Group Insurance Service ,Office of The Lincoln National Life Insurance Company, or its insurance partners, and the initial premium is paid to The Lincoln National Life Insurance Company. A delayed effective date will apply if the employee is not Actively at Work or an Active Member, or a dependent is in a period of limited activity on the date insurance would otherwise take effect. I understand that the vision care insurance benefit plan I have selected provides reimbursement for certain vision costs which are more fully described in the current Certificate of Coverage. I understand there may be instances where treatment decisions made by my provider or me for vision care expenses which I have incurred may not be covered by my vision care insurance benefit plan. Employee Full Name: Employee Signature: Date: GLAD 4 01/12 FL E. Request for Coverages This coverage has been offered to me and after careful consideration of the benefits, I have decided to: ❑ REQUEST COVERAGE for which I am or may become eligible under the group policies issued by The Lincoln National Life Insurance Company. I hereby enroll for group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct premiums from my salary. L NOT ENROLLmyself in the Program. I understand that if I enroll for coverage at a later date, and if a Sys ci al examination or further medical information is required; it will be at my own expense. ❑ NOT ENROLL my dependents in the Program. I understand that if I enroll for coverage for my dependents at a later date, and if a physical examination or further medical information is required, it will be at my own expense. NOTE: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER, FILES A STATEMENT OF CLAIM, OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION, IS GUILTY OF A FELONY OF THE THIRD DEGREE. The insurance requested on this enrollment form will not be effective until approved by the Group Insurance Service .Office of The Lincoln National Life Insurance Company, or its insurance partners, and the initial premium is paid to The Lincoln National Life Insurance Company. A delayed effective date will apply if the employee is not Actively at Work or an Active Member, or a dependent is in a period of limited activity on the date insurance would otherwise take effect. I understand that the vision care insurance benefit plan I have selected provides reimbursement for certain vision costs which are more fully described in the current Certificate of Coverage. I understand there may be instances where treatment decisions made by my provider or me for vision care expenses which I have incurred may not be covered by my vision care insurance benefit plan. Employee Full Name: Employee Signature: Date: GLAD 4 01/12 FL riLi ncoh-, Financial Groupe ENROLLMENT FORM FOR GROUP INSURANCE Please Use Ink or Type I GROUP ID: CITYOFSEB2 I GROUP POLICY #: -A: Employee Inform ion (Comp16fidTor ALL —Enrollments) ---�-- Employer Name/Company Name (Please Print) County I Employer ZIP State City of Sebastian Employee Last Name First Name Middle Initial Social Security Number Date of Birth Spouse Last Name First Name Middle Initial Social Security Number Date of Birth Street Address City State Zip The Lincoln National Life Insurance Company P.O. Box 2616, Omaha, NE 68103-2616 Phone: (800) 423-2765 Fax: (877) 573-6177 Billing Division or Location: Gender: ❑ Male ❑ Female Marital Status: ❑ Married ❑ Single Home Phone Work Phone Completed By Employer Average Hours Worked Per Week: Occupation: Earnings: ❑Hourly ❑Monthly ❑Weekly ❑Yearly Date of Full -Time Employment: Rehire Date: B. Product Selection (Complete for ALL Enrollments) Basic Coverage NOTE: Please mark the box or boxes for each coverage you are applying for. All coverage amounts are subject to the limitations and exclusions as stated in the policy. Class Effective Type of Coverage Amount of Coverage Total Date Premium Basic Group Life/AD&D ❑Yes ❑No* $ Employer Paid Long Term Disability ®Yes ❑No* $ Employer Paid Voluntary Coverage NOTE: Please mark -the box or boxes for each coverage you are applying for. All coverage amounts are subject to the limitations and exclusions as stated in the policy. TYPE OF COVERAGE AMOUNT OF COVERAGE TOTAL PREMIUM Voluntary Employee Life and AD&D Insurance ❑Yes ❑No* S S Voluntary Spouse Life and AD&D Insurance ❑Yes ❑No* S S Voluntary Dependent Child Benefit ❑Yes ❑No* S *By selecting No, application for coverage at a later date may require further medical information and/or a physical exam, which will be at my own expense. --Actual deductions may vary slightly from above illustrations due to rounding— C. Beneficiary Information (Complete ONLY for Life/AD&D or Accident with AD&D) Primary Beneficiary's Last Name First MI I Relationship of Beneficiary I Social Security Number Street Address Contingent Beneficiary's Last Name Street Address City State Zip First MI Relationship of Beneficiary Social Security Number City State Zip Note: A Contingent Beneficiary will receive benefits only if the Primary Beneficiary does not survive you. If you wish to designate more than one Primary or Contingent Beneficiary, please attach a separate sheet of paper. GLAD 4 01/12 FL CMA Building Retirement Security Make convenient paycheck contributions to a 457 deferred compensation plan and a Payroll Roth IRA. 1. Diversify, your taxes — get a tax benefit now for saving to your 457 plan and a tax benefit later when you withdraw from your Roth IRA. www.icmarc.org/457 s *Contributions maybe withdravm at any Time without taxes orpendiex Earrings maybe withdrawn w and penabybee Hymu have awned a kart a fiveyear period and have a gua*ng event, including up 59%: a YiWme home purchase, disabilly or death. Otherwise, income a may apply. See IRS Ibbrhcobon 590. 2. Use for different goals —retirement, healthcare, anew home Even small saving can really add up, especially if you gradually increase it over time. If you contribute just $10 biweekly and increase that $5 per year... Your account could be worth... $10,686 Far rlluslumve purposes only. Assumes on effernue 6%overage ounud reNm, compounded biweekly and conhibutions of $10 the first year and $5 yeary increases therealkr ($15 biweekly in the second year, 520 the third year, ek.) Roth IPA for at id penalty Was To learn more, contact your ICMA-RC representative: Torri p;ila— Retirement Plans Specialist tchronister@icmarc.org , S41930 $133,531 ICMA RETIREMENT CORPORATION • 777 NORTH CAPITOL STREET, HE • WASHINGTON, 0C 20002-4240 TEL: 202-962-4600 • FAX: 202.962-4601 • TOLL FREE 800-669-7400 • EN ESPANOL LLAME AL 800-669-8216 • INTERNET. WWWI (MARC. ORG nLincoln Financial Group® September 25, 2019 CITY OF SEBASTIAN CYNTHIA WATSON 1225 MAIN STREET SEBASTIAN, FL 32958-4165 Dear Policyholder: The Lincoln National Life Insurance Company 8801 Indian Hills Drive Omaha, NE 68114-4066 tall free (8001423-2765 Protecting the privacy of our customers' personal information is of utmost importance at Lincoln Financial Group. We keep confidential all nonpublic personal information as required by the Gramm -Leach -Bliley Act ("GLBA"). GLBA requires Lincoln to provide policyholders with a copy of Lincoln's GLBA Privacy Notice ("Notice") on an annual basis. A copy of Lincoln's Notice is included with this lelter. Please distribute a copy of this Notice to insureds. In addition, Lincoln's Notice; is included in our insurance certificates and is available on our web sites at www.ifq.com and www.lincolrrfinancial.com.. Lincoln Financial Group will only disclose confidential information with written authorization from the insured. If you have questions or concerns on regarding this Notice, please email us at: clientservices(a�lfoxom or call our Client Services area at 1-800-423-2765. Sincere!;, Lincoln Financial Group 8801 Indian Hills Dr Omaha NE 68114 ME 0 Q 0 0 0 0 Lincoln Financial Group* Lincoln Financial Group° Privacy Practices Notice The Lincoln Financial Group companies* are committed to protecting your privacy. To provide the products and services you expect from a financial services leader, we must collect personal information about you. We do not sell your personal information to third parties. This Notice describes our current privacy practices. While your relationship with us continues, we will update and send our Privacy Practices Notice as required by law. Even after that relationship ends, we will continue to protect your personal information. You do not need to take any action because of this Notice, but you do have certain rights as described below. Information We May Collect And Use We collect personal information about you to help us identify you as our customer or our former customer; to process your requests and transactions; to offer investment or insurance services to you; to pay your claim; to analyze in order to enhance our products and services; or to tell you about our products or services we believe you may want and use; and as otherwise permitted by law. The type of personal information we collect depends on the products or services you request and may include the following: • Information from you: When you submit your application or other forms, you give us information such as your name, address, Social Security number; and your financial, health, and employment history. = Information about your transactions: We maintain information about your transactions with us, such as the products you buy from us; the amount you paid for those products; your account balances; and your payment and claims history. • Information from outside our family of companies: If you are purchasing insurance products, we may collect information from consumer reporting agencies such as your credit history; credit scores; and driving and employment records. With your authorization, we may also collect information, such as medical information from other individuals or businesses. • Information from your employer: If your employer purchases group products from us, we may obtain information about you from your employer in order to enroll you in the plan. How We Use Your Personal Information We may share your personal information within our companies and with certain service providers. They use this information to process transactions you have requested; provide customer service; to analyze in order to enhance our products and services; and inform you of products or services we offer that you may find useful. Our service providers may or may not be affiliated with us. They include financial service providers (for example, third party administrators; broker -dealers; insurance agents and brokers, registered representatives; reinsurers and other financial services companies with whom we have joint marketing agreements). Our service providers also include non -financial companies and individuals (for example, consultants; vendors; and companies that perform marketing services on our behalf). Information we obtain from a report prepared by a service provider may be kept by the service provider and shared with other persons; however, we require our service providers to protect your personal information and to use or disclose it only for the work they are performing for us, or as permitted by law. When you apply for one of our products, we may share information about your application with credit bureaus. We also may provide information to group policy owners, regulatory authorities and law enforcement officials, and to other non-affiliated or affiliated parties as permitted by law. In the event of a sale of all or part of our businesses, we may share customer information as part of the sale. We do not sell or share your information with outside marketers who may want to offer you their own products and services; nor do we share information we receive about you from a consumer reporting agency. You do not need to take any action for this benefit. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Page 1 of 2 GB06714 12/17 Security of Information We have an important responsibility to keep your information safe. We use safeguards to protect your information from unauthor- ized disclosure. Our employees are authorized to access your information only when they need it to provide you with products, services, or to maintain your accounts. Employees who have access to your personal information are required to keep it confi- dential. Employees are required to complete privacy training annually. Your Rights Regarding Your Personal Information Access: We want to make sure we have accurate information about you. Upon written request we will tell you, within 30 business days, what personal information we have about you. You may see a copy of your personal information in person or receive a copy by mail, whichever you prefer. We will share with you who provided the information. In some cases we may provide your medical information to your personal physician. We will not provide you with information we have collected in connection with, or in anticipation of, a claim or legal proceeding. If you request a copy of the information, we may charge you a fee for copying and mailing costs. In very limited circumstances, your request may be denied. You may then request that the denial be reviewed. Accuracy of Information: If you feel the personal information we have about you is inaccurate or incomplete, you may ask us to amend the information. Your request must be in writing and must include the reason you are requesting the change. We will respond within 30 business days. If we make changes to your records as a result of your request, we will notify you in writing and we will send the updated information, at your request, to any person who may have received the information within the prior two years. We will also send the updated information to any insurance support organization that gave us the information, and any service provider that received the information within the prior 7 years. If your requested change is denied, we will provide you with reasons for the denial. You may write to request the denial be reviewed. A copy of your request will be kept on file with your personal information so anyone reviewing your information in the future will be aware of your request. Accounting of Disclosures: If applicable, you may request an accounting of disclosures made of your medical information, except for disclosures: • For purposes of payment activities or company operations; • To the individual who is the subject of the personal information or to that individual's personal representative; • To persons involved in your health care; • For notification for disaster relief purposes; • For national security or intelligence purposes; • To law enforcement officials or correctional institutions; • Included in a limited data set; or • For which an authorization is required. You may request an accounting of disclosures for a time period of less than six years from the date of your request. Basis for Adverse Underwritina Decision: You may ask in writing for the specific reasons for an adverse underwriting decision. An adverse underwriting decision is where we decline your application for insurance, offer to insure you at a higher than standard rate, or terminate your coverage. Your state may provide for additional privacy protections under applicable laws. We will protect your information in accordance with these additional protections. Questions about your personal information should be directed to: Lincoln Financial Group Attn: Enterprise Compliance and Ethics Corporate Privacy Office, 7C-01 1300 S. Clinton St. Fort Wayne, IN 46802 Please include all policy/contract/account numbers with your correspondence. *This information applies to the following Lincoln Financial Group companies: First Penn -Pacific Life Insurance Company Lincoln Financial Group Trust Company, Inc Lincoln Investment Advisors Corporation Lincoln Financial Distributors, Inc. Lincoln Life & Annuity Company of New York Lincoln Retirement Services Company, LLC Lincoln Variable Insurance Products Trust The Lincoln National Life Insurance Company GB06714 Page 2 of 2 12/17 Security of Information We have an important responsibility to keep your information safe. We use safeguards to protect your information from unauthor- ized disclosure. Our employees are authorized to access your information only when they need it to provide you with products, services, or to maintain your accounts. Employees who have access to your personal information are required to keep it confi- dential. Employees are required to complete privacy training annually. Your Rights Regarding Your Personal Information Access: We want to make sure we have accurate information about you. Upon written request we will tell you, within 30 business days, what personal information we have about you. You may see a copy of your personal information in person or receive a copy by mail, whichever you prefer. We will share with you who provided the information. In some cases we may provide your medical information to your personal physician. We will not provide you with information we have collected in connection with, or in anticipation of, a claim or legal proceeding. If you request a copy of the information, we may charge you a fee for copying and mailing costs. In very limited circumstances, your request may be denied. You may then request that the denial be reviewed. Accuracy of Information: If you feel the personal information we have about you is inaccurate or incomplete, you may ask us to amend the information. Your request must be in writing and must include the reason you are requesting the change. We will respond within 30 business days. If we make changes to your records as a result of your request, we will notify you in writing and we will send the updated information, at your request, to any person who may have received the information within the prior two years. We will also send the updated information to any insurance support organization that gave us the information, and any service provider that received the information within the prior 7 years. If your requested change is denied, we will provide you with reasons for the denial. You may write to request the denial be reviewed. A copy of your request will be kept on file with your personal information so anyone reviewing your information in the future will be aware of your request. Accounting -of Disclosures: If applicable, you may request an accounting of disclosures made of your medical information, except for disclosures: • For purposes of payment activities or company operations; • To the individual who is the subject of the personal information or to that individual's personal representative; • To persons involved in your health care; • For notification for disaster relief purposes; • For national security or intelligence purposes; • To law enforcement officials or correctional institutions; • Included in a limited data set; or • For which an authorization is required. You may request an accounting of disclosures for a time period of less than six years from the date of your request. Basis for Adverse Underwriting Decision: You may ask in writing for the specific reasons for an adverse underwriting decision. An adverse underwriting decision is where we decline your application for insurance, offer to insure you at a higher than standard rate, or terminate your coverage. Your state may provide for additional privacy protections under applicable laws. We will protect your information in accordance with these additional protections. Questions about your personal information should be directed to: Lincoln Financial Group Attn: Enterprise Compliance and Ethics Corporate Privacy Office, 7C-01 1300 S. Clinton St. Fort Wayne, IN 46802 Please include all policylcontractlaccount numbers with your correspondence. *This information applies to the following Lincoln Financial Group companies: First Penn -Pacific Life Insurance Company Lincoln Financial Group Trust Company, Inc Lincoln Investment Advisors Corporation Lincoln Financial Distributors, Inc. Lincoln Life & Annuity Company of New York Lincoln Retirement Services Company, LLC Lincoln Variable Insurance Products Trust The Lincoln National Life Insurance Company G606714 Page 2 of 2 12/17